DTI Participants Symptom Check Form

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. We thank you for your care and cooperation.
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
Do you have any symptoms of Covid-19, influenza or other respiratory infection? e.g. runny nose, cough, sore throat, fever, headaches, muscle pain, fatigue *

Yes No
Have you tested positive for Covid-19 infection in the last 7 days *

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
By signing this form, you accept the risk that you may inadvertently be exposed to infection during your visit and that your safety depends in large part on your behaviour.

Please also let us know. If there are any other circumstances relating to COVID-19, not included in this form, which we should know about, just let us know.
Signature *

Clear
Date completing form

Month Day Year
Date
Should be Empty:

DTI Participants Symptom Check Sheet