All About Dance COVID-19 Self Assessment Contact Tracing Questionnaire

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In order for your child's admittance into class, I would appreciate if you could take some time and fill out this survey ONE HOUR prior to their class time. Please understand without this completed form, your child may not enter dance class. Thanks so much. Miss Lisa

Are you, your dancer or anyone in your household experiencing any of the following symptoms (not related to chronic/known conditions or seasonal allergies: Cough, Fever, Shortness of breath, Headaches, Fatigue, Congestion, Runny nose, Sore Throat, Sever Muscle Aches, Nausea, Vomiting, Diarrhea, Rash, Loss of Sense, Taste or Smell? *

Yes

Other:

Have you, your dancer or anyone in your household (to the best of your knowledge) been in direct contact with anyone that has tested positive for COVID-19 in the past 14 days? *

Yes

Has your dancer traveled out of the State of Massachusetts in the past 14 days? *

Yes

Child's Full Name *

Parent's Full Name *

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