Covid-19 Screening Form | Goddards Studio

Dancers Full Name

Date of Dance Class

Parent/Guardian's Full Name

Phone

Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

Fever and/or Chills (Temperature of 37.8 degrees celsius/100 degrees fahrenheit or higher?

Cough or barking cough (croup) - Not related to Asthma, Post-Infectious Reactive Airways, COPD, or other known causes or conditions you already have?

Shortness of Breath - Not related to asthma or other known causes or conditions you already have

Decrease or loss of smell or taste - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

(For adults > 18 years or older) Fatigue. Lethargy, Malaise and/or Myalgias - Unusual tiredness, lack of energy (not related to Depression, Insomnia, Thyroid Dysfunction or other known causes or conditions you already have)

(For children < 18 years) Nausea, Vomiting and/or Diarrhea - Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have

None of the Above

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

Yes

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate (e.g. you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”

Yes

Parent/Guardian's reason for entering Goddards Studio.

I am volunteering assisstance for my child in his/her dance class

I am entering the studio to drop off my child, I will not be remaining on the premises

I am making a payment or enquiry, I will not be remaining on the premises

Are you fully vaccinated with proof of double vaccination?

Yes, I have proof of my vaccination passport

I am partially vaccinated

No, I am not vaccinated

No, I have proof of an exemption

I do not wish to disclose any medical information

(905) 699-4747

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Covid-19 Active Screening Form