COVID-19

Dancers First and Last Name *

*If a parent/Guardian is entering... You must fill out another form with parent/Guardian name as well

Phone Number *

Date / Time (Of your first class) *

Date

Time

Are you currently experiencing any of these symptoms? Answer YES or NO to each Sympton.

FEVER - (Temperature of 37.8 degrees Celsius/100 Degrees Fahrenheit or higher) *
Yes
No

CHILLS *
Yes
No

COUGH - that's new or worsening Continuous, more than usual, not related to other known causes or conditions (for example, COPD) *
Yes
No

SHORTNESS OF BREATH - Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma) *
Yes
No

SORE THROAT - Not related to other known causes or conditions (for example, seasonal allergies, acid reflux) *
Yes
No

RUNNY NOSE - Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather) *
Yes
No

DIFFICULTY SWALLOWING - Painful swallowing, not related to other known causes or conditions *
Yes
No

STUFFY OR CONGESTED NOSE - Not related to other known causes or conditions (for example, seasonal allergies) *
Yes
No

DECREASE OR LOSS OF TASTE OR SMELL - Not related to other known causes or conditions (for example, allergies, neurological disorders) *
Yes
No

PINK EYE - Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes) *
Yes
No

HEADACHE that’s unusual or long lasting - Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines) *
Yes
No

DIGESTIVE issues like nausea/vomiting, diarrhea, stomach pain - Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps) *
Yes
No

MUSCLE ACHES that are unusual or long lasting - Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia) *
Yes
No

Extreme tiredness that is unusual - Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction) *
Yes
No

Falling down often - More than usual *
Yes
No

Have you been in close physical contact with someone that has a confirmed or probable case of COVID-19? *
Yes
No
This includes getting a COVID Alert exposure notification. Close physical contact means: being less than 2 metres away in the same room, workspace, or area living in the same home being in the same classroom

Have you returned from travel outside of Canada in the last 14 days? *
Yes
No

If you answered YES to any of these questions, go home & self-isolate right away.

Visit hamiltion.ca/coronavirus for more information as you may be eligible for a COVID-19 test.

If feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.

If you answered NO to all of these questions, you can go attend your activity.

I consent for my child to be spotted and/or receive tactile corrections from their teachers. Proper mask-wearing and sanitizing will be followed. *
Yes
No

I will inform Pure Energy Performance Inc. if my child develops any of the symptoms listed above. Parent/Guardian name required below. *
I Agree

I consent to Pure Energy Performance Inc. releasing this information to Public Health in the event it is needed to assist with contact tracing. *
Parent/Guardian Name *Dancers Name if over 18 Years of age.

Please complete the following questions before beginning your class today.

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