COVID-19 NOVEL CORONAVIRUS

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 *

Date

Time

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions. *

Fever - (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)
Chills
Cough - that's new or worsening Continuous, more than usual, not related to other known causes or conditions (for example, COPD)
Barking cough, making a whistling noise when breathin Croup, not related to other known causes or conditions
Shortness of breath - Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)
Sore throat - Not related to other known causes or conditions (for example, seasonal allergies, acid reflux)
Difficulty swallowing - Painful swallowing, not related to other known causes or conditions
Runny nose - Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)
Stuffy or congested nose - Not related to other known causes or conditions (for example, seasonal allergies)
Decrease or loss of taste or smell - Not related to other known causes or conditions (for example, allergies, neurological disorders)
Pink eye - Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes)
Headache that’s unusual or long lasting - Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)
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)
Muscle aches that are unusual or long lasting - Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia)
Extreme tiredness that is unusual - Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction)
Falling down often - For older people
Sluggishness or lack of appetite - For young children and infants
None of the above *Check here is you have none of the above symptons.

In the last 14 days, have you been in close physical contact with someone who currently has 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

This does not include essential workers who cross the Canada-US border regularly.

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.

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 consent to Pure Energy Performance Inc. releasing this information to Public Health in the event it is needed to assist with contact tracing. I will inform Pure Energy Performance Inc. if my child develops any COVID-19 symptoms or if they are diagnosed with COVID-19 within the next 14 days. **Enter Parent or Guardians name below. *

Please complete the following questions before beginning your class today.

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