COVID-19 Participant Questionnaire

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The safety of our employees, customers, families and visitors remain a priority for Dance Fusion Studio, Inc. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, Dance Fusion Studio Inc. will be monitoring the situation closely and will periodically update our policies and procedures based on current recommendations from the Centers for Disease Control and Prevention and the World Health Organization. Only students are permitted to enter our facility at this time. To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

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Parent Full Name *

Student First Name *

Student Last Name *

Phone Number *

Within the last 10 days has the above named student been diagnosed with COVID-19 or had a test confirming he/she have the virus? *

Yes

必須

Has the student named above had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *

Yes

必須

Has the student named above experienced any cold or flu-like symptoms in the last 14 days (to include fever above 100 degrees, cough, sore throat, respiratory illness, difficulty breathing)? *

Yes

必須

I have read and will abide by the policies designated by Dance Fusion Studio, Inc. and I have filled out the WAIVER/RELEASE FOR COMMUNICABLE DISEASES INCLUDING COVID-19 ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT.

必須

送信

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