Dancer Name *

First Name

Last Name

Within the last 10 days have you or anyone in your household been diagnosed with COVID-19 or had a test confirming the virus? *

Yes

No

Have you or anyone in your household had one or more of the below-listed symptoms today or within the past 24 hours, which is new or not explained by another reason? *

Fever or chills

Cough

Shortness of breath of 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

I certify that the above information is accurate and that I/my dancer is not putting our class at risk. *

This serves as my digital signature.