The Dancing Elephant COVID-19 Survey

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We care deeply about the health of our students, teachers, and community. As we re-open to small, in-person classes both indoors and outdoors, we ask every student to review our COVID-19 Health Protocols posted on our website and to answer the questions below before coming to class. If you answer "Yes" to any of the COVID-19 health questions or do not meet the State of Maine entry criteria, you unfortunately are not allowed to attend in-person classes at this time. You may join our online classes via Zoom. Visit www.rockland.com for more information about all of our classes. Thank you!

Date *

YYYY

Your Full Name *

Your Email Address *

The class or retreat you plan to attend: *

Weekly yoga class at the studio

Please read the COVID-19 Health Protocols on The Dancing Elephant website (www.rocklandyoga.com/general-guidelines). Thank you. *

Yes, I have read and understand the protocols.

No, I have not read them.

COVID-19 Health Questions: Do you currently have – or have you had in the last 14 days – any of the following symptoms: fever, chills, sore throat or cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, new loss of taste or smell, or nausea, vomiting or diarrhea? *

Yes

Have you come in contact with any known or suspected COVID-19 cases in the last 14 days? *

Yes

Have you had close, sustained contact with large groups of people in the past 14 days? *

Yes

Have you traveled to a non-exempt state in the past 14 days? www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/travel.shtml *

Yes (if yes, please provide more details about your travels under "other information" at the end of the survey)

Please check the box that best describes how you comply (or not) with the State of Maine COVID-19 entry criteria: *

I am from Maine.

I am from one of the exempt states listed at www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/coronavirus/travel.shtml

I am from a non-exempt state, and I have quarantined for 10 days.

I am from a non-exempt state, and I have passed a COVID-19 test within the last 72 hours.

I am from a non-exempt state, and I have completed the COVID-19 vaccination series (more than 14 days ago).

I am from a non-exempt state, and I previously tested positive for COVID-19 (more than 90 days prior) and am now asymptomatic.

I am from out-of-state, and I do not comply with any of the above.

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY: I agree that my current health and physical condition support my participation in programs at The Dancing Elephant. I agree that I am ultimately responsible for my own safety and for participating as I am able. I acknowledge that I am participating at my own risk. If I have questions about my health, I will consult with my physician and seek his/her approval for participation if necessary. I release and waive any liability or claim I may have resulting from participation in classes at The Dancing Elephant. I have read this Agreement of Release and Waiver of Liability, and I fully understand its contents. I voluntarily agree to the terms and conditions stated above. *

Yes

I understand that I need to bring my own yoga mat and any props that I need with me to class. (Note: Please email rachel@rocklandyoga.com if you would like to purchase any yoga supplies from the studio -- yoga mat, blanket, blocks, bolsters, etc. They are in good condition.) *

Yes

Are you vaccinated? *

Yes! Fully vaccinated (two weeks after final dose or J&J vaccine)

No. Not fully vaccinated

If you have any other information to share with us, including details of out-of-state travel, please respond here. Thank you for helping to keep our community safe and healthy!

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