DTI Participants Symptom Check Sheet

Name *

First Name Last Name

EventBrite Ticket Order number

Job Title / Class/ Time *

Phone Number *

Email *

example@example.com

Date of Activity *

Date

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

Date

DTI Participants Symptom Check Sheet

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