COVID-19 Health Check

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Artistry in Motion Performing Arts Center

First Name *

Last Name *

Date of Birth *

YYYY

Has anyone in your household traveled outside of the United States of America in the last 14 days? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility *

Yes

Has anyone in your household had contact with anyone with suspected or confirmed COVID-19 in the last 14 days? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility.) *

Yes

Has anyone in your household had any of these symptoms in the last 14 days: fever, chills, difficulty breathing or shortness of breath, dry cough? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility.) *

Yes

Is anyone in your household currently experiencing fever, difficulty breathing or cough? (Answering YES may prompt us to ask you more questions to determine if you are eligible to enter our facility.) *

Yes

I understand by filling out this form, AIMPAC, it's staff, and instructors will be this released of all liabilities as they will undergo the same protocol as our families, whether a COVID-19 infection occurs before, during, or after participation in any program. I understand that answering "no" could result in AIMPAC denying myself and my family from entering Artistry in Motion's facility. Do you agree that you have read and accept the Virus Acknowledgement? *

Yes

I am filling out this form on behalf of: *

Myself

A minor

Please confirm your answers by selecting below: *

I certify that the information I have provided is accurate and complete.

Required

Signature

Today's date

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Wellness by Nature. Report Abuse

Forms