COVID-19 Health Questionnaire

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I understand that the risk of becoming exposed to or infected by COVID-19 at Union Street Dance may result in the actions, omissions, or negligence of myself, and others, including but not limited to, Participants, and Union Street Dance employees, volunteers, program participants and their families.

Full Name (First, Last) *

Phone number *

Email address

Are you experiencing any of the following symptoms? *

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

None of the Above

Required

Have you received a COVID-19 vaccine? *

Yes

Partial Dose

I have filled out the Proof of Vaccination form *

Yes

Have you or someone you live with been in contact with someone who has tested positive for COVID-19 in the past 10 days? *

Yes

I'm not sure

If you have been exposed within the past 10 days, you are required to wear a face mask at all times while in the studio space and make full use of the studio's HEPA air filtration systems *

I understand

Required

If you have tested positive for COVID-19 within the past 10 days, we encourage you to quarantine and will reschedule your rental for after the 10 day period. If you are asymptomatic, and it has been 5 days since your positive test, you are able to keep your rental BUT ARE REQUIRED TO WEAR A FACE MASK AT ALL TIMES AND MAKE FULL USE OF THE HEPA AIR FILTRATION SYSTEMS *

I understand

Required

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