COVID-19 Dance Lesson Consent Form

COVID-19 Dance Lesson Consent Form

By submitting this form, you agree to have in-person private or group dance lessons during the pandemic.
Student Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
By checking the boxes, you confirm that you agree with the following statements:

I understand that I have a risk of contracting virus during the service. I agree to obey the rules of the studio during my appointment in order to minimize the spread of viruses. I confirm that I have not been diagnosed with COVID-19 or tested positive in the last 14 days. I verify that I am not waiting for the laboratory test results for COVID-19. I have not traveled or returned from travel in the last 2 weeks. This includes anywhere out of the country or domestically with the US via plane, bus or train. I do NOT have a fever of 100.4 degrees or higher
Do you have any of these symptoms? - cough, shortness of breath, high fever, muscle pain, body ache, fatigue, nausea, loss of taste/smell

Yes No
Within 14 days, have you been in contact with anyone that has COVID-19 symptoms or gotten infected?

Yes No Other
Are you living with anyone that been infected or quarantined due to COVID-19?

Yes No
I agree NOT to visit the studio for any of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.
Parent/Guardian Name (if applicable)

First Name Last Name
Date

Month Day Year
Client/Parent/Guardian Signature

Clear
Should be Empty:

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