PUA Student of the Week Showcase 
We here at Palms Up Academy love to be communal and invite others to our intersection; but with that comes the responsibility of cultivating a safe, healthy space that all attendees can feel comfortable in.  

PLEASE NOTE: complete a self-assessment and submit this form 2 days prior to the in-person event/class you trying to attend.  Do NOT come to PUA in-person events or classes if you have had symptoms consistent with COVID-19, or have been exposed/tested positive for COVID-19.

Additionally, please answer truthfully to questions regarding your COVID-19 vaccination status, and only yours.  Your information will not be shared and is confidential to the staff of Palms Up Academy.  

**RECESS Mic at LACPA & Student of the Week Showcase (with Kumu USA) are outdoor and indoor public events respectively; and both take place in a location that is open to children.  To date, those 5 years and over can receive the COVID-19 vaccine, but it is not guaranteed that every minor in attendance to either event will have received the vaccine.  In order to keep safe, you will be asked to provide evidence to the answers you submit below to confirm your RSVP (i.e. negative COVID-19 test confirmation email, vaccine card).  Additionally, you will be required to sign off on a disclaimer for LACPA and/or Palms Up Academy releasing the location managers and staff of any liability should you fall ill after attending either event.
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Event / Class of Interest *
For SOTW @ Kumu USA, information on parking and directions to studio will be provided the MONDAY prior to the showcase date you wish to attend in person.
The showcase dates & acts include:
- June 8th (Austin Howell)
- June 15th (Derek Brown)
- June 22nd (Sav)
- June 29th (Mr. Chai Tea)
Are you feeling sick? *
In the last two weeks, did you have close contact with someone with symptoms of COVID-19, tested for COVID-19, or diagnosed with COVID-19?  (Close contact is when you are within 6 feet of an infected person for at least 15 minutes).   *
Do you have any of the following symptoms? *
Required
When was the last time you were tested for COVID-19?  Please provide the specific date. *
MM
/
DD
/
YYYY
What was the result of that COVID-19 test? *
If you are contacted by a PUA staff member advising you to update your COVID testing, you can find rapid testing near you for free at www.curative.com.  
Have you been vaccinated for COVID-19?
Clear selection
If you answered "Yes" or "Need second booster" to the previous question, please have your vaccination card ready on-site at the event / class.  
FOR RECESSMIC & SOTW: By checking this box, I consent to not hold LACPA, Kumu USA or any staff personally responsible should I, or anyone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus.  I assume full responsibility for personal illness that may result and further release and discharge LACPA/Kumu USA staff for injury, loss or damage arising out of my visit.  I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure.   *
Required
FOR PALMS UP MARTIAL ARTS: By checking this box, I consent to not hold Palms Up Academy or any of its staff personally responsible should I, or anyone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus.  I assume full responsibility for personal illness that may result and further release and discharge PUA staff for injury, loss or damage arising out of my visit.  I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure.   *
Required
By checking this box, I hereby affirm that the answers I provided above are true and correct to the best of my knowledge.  I understand that my COVID-19 vaccination status does NOT determine whether or not I can attend a PUA event / class, but my answers to the previous questions will.  I also intend to email PUA immediately if the status of my health changes prior to the event / class I am interested in.  If I fail to do so, I consent to having PUA staff escort me off the premises in the interest of public health and safety.   *
Required
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms