COVID FORM Consent You must wear a mask at all times on site. THE INDUSTRY Dance Academy staff will be taking your temperature and will be requiring you to disinfect your hands. After your classes, please wash and/or disinfect your hands. 1. Do you have any of the following COVID-19 symptoms now or within the past 7 days?*Shortness of breath, Fever of 100.4 or above, Chills, Cough, Repeated shaking with chills, Muscle pain, Headache, Sore throat New loss of taste or smell, Vomiting, Diarrhea, Congestion or Runny Nose, Hives or rash No Yes 2. Have you tested positive for COVID-19 in the past 14 days?* No Yes 3. Has your child come into close contact (within 6 feet) with someone who has a laboratory-confirmed COVID 19 diagnoses in the past 14 days, A person who has symptoms compatible with COVID 19, A person who is on quarantine for exposure for COVID 19??* No Yes I certify that the information submitted in this assessment is true and correct to the best of my knowledge. (Please sign digitally using forward slashes e.g. /Jane Smith) If you answered YES to any of these questions, you understand that you will be asked to reschedule. The safety of our clients and staff is the most important thing. We appreciate your understanding.Email Your Name* Your first name Your last name Date* MM slash DD slash YYYY
