DTI Participants Symptom Check Sheet

DTI Participants Symptom Check Sheet

* If you are attending a Morning Class, you must complete and submit this form not later than 6pm the night before each Class. * If you are attending an Evening Class, you must complete and submit the form not later than 12 Noon the day of the class. Thank you.
Name *

First Name Last Name
EventBrite Ticket Order number
Job Title / Class/ Time *
Phone Number *
Email *
example@example.com
Date of Activity *

Month Day Year
Date
Please answer the following questions: "Have you or anyone in your family/group" :
Had a cough, fever, sore throat, runny nose, or flu like symptoms now or in the past 14 days? *

Yes No
Have you had a confirmed or suspected Covid 19 infection in the last 10 days (or since I saw you)? *

Yes No
Do you have a close contact or family member who is a confirmed or suspected case of COVID-19 in the past 10 days (or since I saw you)? (i.e. less than 2m for more than 15 minutes accumulative in 1 day) *

Yes No
Have you or any member of your family been advised by a doctor to self isolate at this time? *

Yes No
I agree if the answer is yes to any of the above, I will contact Dance Theatre of Ireland and will not attend classes / activities. *

Yes No
If at any time you start to display symptoms of Covid-19 you should not come into DTI. You should self-isolate at home and contact your GP promptly for further advice. Please also inform DTI f this situation arises.

You should let us know if there are any other circumstances relating to COVID-19, not included in this form, which we may need to know about.
Signature *

Clear
Date completing form

Month Day Year
Date
Should be Empty:

DTI Participants Symptom Check Sheet

Please answer the following questions: "Have you or anyone in your family/group" :