COVID-19 Declaration Form & Release (Furor)

2020 COVID-19 Declaration Form and Release

**Signature Required Prior to Dance Classes**
Trusare LLC ( Downtown Dance Conservatory)

and anyone else involved in the operations of the studio's premises, including but not limited to, instructors, visiting faculty and staff (are hereinafter referred to as "DDC").
Age of Consent *

I am an Adult over the age of Eighteen (18). The Student is a Minor under the age of Eighteen (18).
Minor Student's Name in Full

Given Name Family Name
COVID-19 Common Symptoms, as per WHO:

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
I agree to the following: *

I understand the aforementioned COVID-19 symptoms. I affirm that neither I, nor any member of my household, currently has or has experienced the aforementioned symptoms within the past 14 days. Furthermore, I will immediately inform DDC and discontinue classes if I, or any member of my household, develops any of the aforementioned symptoms. I affirm that neither I, nor any member of my household, has been diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform DDC and discontinue classes if I, or any member of my household, is diagnosed with COVID-19. I affirm that neither I, nor any member of my household, has knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform DDC and discontinue classes if I, or any member of my household, is knowingly exposed to anyone diagnosed with COVID-19. I affirm that neither I, nor any member of my household, has traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30 days. Furthermore, I will immediately inform DDC and discontinue classes once I, or any member of my household, returns from traveling outside of the country or to any city considered to be a "hot spot" for COVID-19 infections. I understand that the DDC cannot be held liable for any exposure to the COVID-19 virus caused by any misinformation on this form or the health history provided by each Student. Any legal disputes with DDC will be subject to Clark County Jurisdiction.
I agree to the following:

I understand the aforementioned COVID-19 symptoms. I affirm that neither the Student, nor any member of our household, currently has or has experienced the aforementioned symptoms within the past 14 days. Furthermore, I will immediately inform DDC and discontinue classes if the Student, or any member of our household, develops any of the aforementioned symptoms. I affirm that neither the Student, nor any member of our household, has been diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform DDC and discontinue classes if the Student, or any member of our household, is diagnosed with COVID-19. I affirm that neither the Student, nor any member of our household, has knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform DDC and discontinue classes if the Student, or any member of our household, is knowingly exposed to anyone diagnosed with COVID-19. I affirm that neither the Student, nor any member of our household, has traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30 days. Furthermore, I will immediately inform DDC and discontinue classes once the Student, or any member of our household, returns from traveling outside of the country or to any city considered to be a "hot spot" for COVID-19 infections. I confirm that I am the Parent or Legal Guardian of the Student. I understand that DDC cannot be held liable for any exposure to the COVID-19 virus caused by any misinformation on this form or the health history provided by each Student. Any legal disputes with DDC will be subject to Clark County Jurisdiction.
DDC will be adhering to the following enhanced procedures to prevent the spread of COVID-19.

Our instructors and staff will…
- Do a temperature check before entering the studio, and ensure that it is below 38.0°C.
- Clean/Disinfect frequently touched surfaces thoroughly and at regular intervals.
- Wash/Sanitize our hands before and after each session.
- Wear our masks at all times.
- Maintain a safe distance at all times.
- Accommodate a limited number of students in each class to ensure physical distancing.
- Schedule classes so as to allow time for cleaning/disinfecting surfaces and allow students to finish and leave the studio before the next set of students arrive.
- Provide sanitizers in the reception area and other locations within the premises.
We are requesting that each of our students, please…
- Allow us to check their temperature before entering the premises to ensure it is below 38.0°C.
- Wear a face mask at all times within the building and within the studio.
- Maintain a safe distance from others at all times.
- Use the hand sanitizer before entering and while exiting the studio.
- Carry their own bottle or cup for drinking water.
By signing below, I agree to each statement above and release DDC from any and all liability for the unintentional exposure or harm due to COVID-19. DDC agrees to abide by these standards and affirms the same.
Student's Name in Full *

Given Name Family Name
Parent or Guardian's Name in Full

Given Name Family Name
Mobile Number *
Do not include "0" or "+91"
Email ID *

Confirmation Email example@example.com
Signature *

Please sign above Clear
Date

Day Month Year
Date of Submission
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2020 COVID-19 Declaration Form and Release

Trusare LLC ( Downtown Dance Conservatory)