COVID-19

I am taking this screening as a: *

Student/Child
Parent/guardian on behalf of a student/child
Employee
Visitor

You must choose one of the above.

First and Last Name *

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

Phone Number *

This information is for Contact Tracing. Thank you!

Please record the Date of Class(es) *

This information is for Contact Tracing. Thank you!

Start Time - Finish Time *

This information is for Contact Tracing. Thank you!

In the last 14 days, have you or student/child travelled outside of Canada AND: •been advised to quarantine as per the federal quarantine requirements AND/OR •is the student/child under the age of 12 and not fully vaccinated? *

Yes
No

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

Yes
No

This can be because of an outbreak or contact tracing.

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

Yes
No

If public health has advised you that you do not need to self-isolate, select “No.”

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? *

Yes
No

If you already went for a test and got a negative result, select "No."

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

Yes
No

If the person got a COVID-19 vaccine in the last 48 hours and is experiencing a mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *

Yes
No

If you have since tested negative on a lab-based PCR test, select "No."

Fever and/or chillsTemperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher *

Yes
No

Cough or barking cough (croup)Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have) *

Yes
No

Shortness of breathOut of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have) *

Yes
No

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

Yes
No

Muscle aches/joint pain Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have) *

Yes
No

Extreme tiredness Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) *

Yes
No

If you answered YES to any of these questions, go home & self-isolate. Call Telehealth or your health care provider to find out if you need a test. If you answered NO to all of these questions, you can attend your activity. The above questions are used to screen for COVID-19 before entry, as per direction from the Medical Officer of Health.

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 consent to Pure Energy Performance Inc. releasing this information to Public Health in the event it is needed to assist with contact tracing. (copy) *

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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