COVID-19 Questionnaire
Daily Health Screening for your Studio 21 dancer
If you answer "YES" to any of the questions below, your dancer is unable to attend dance class today. We ask that you please use the virtual option for class via ZOOM or provide proof of a negative COVID-19 test.
Dancer Name
*
First Name
Last Name
Today's Date:
*
-
Month
-
Day
Year
Date
Has your child or anyone in your household had a fever (greater than 100 degrees F) or symptoms of respiratory illness such as cough, sore throat, difficulty breathing or shortness of breath within the last 24 hours?
*
YES
NO
Has your child or anyone in your household experienced loss of taste or smell?
*
YES
NO
Has your child or anyone in your household had a confirmed case of COVID-19 or awaiting tests related to a suspected COVID-19 diagnosis within the last 10 days?
*
YES
NO
Has your child or anyone in your household been in close contact with someone who has a confirmed case of COVID-19 or awaiting tests related to a suspected COVID-19 diagnosis within the last 10 days?
*
YES
NO
Has your child or anyone in your household traveled to a high risk (COVID-19) state or country within the last 10 days?
*
YES
NO
Has your child or anyone in your household come in contact with someone who has traveled to a high risk (COVID-19) state or country within the last 10 days?
*
YES
NO
Please provide additional info here: (if necessary)
QUESTIONS ANSWERED BY:
*
First Name
Last Name
*
I affirm that all questions above were answered truthfully to the best of my knowledge.
Signature
*
Submit
Should be Empty: