COVID Survey - Gibsons Dance Centre

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COVID 19 Screening Survey

* Indicates required field

Students First & Last Name *

Do you or anyone in your household currently have any of the following symptoms? *

Fever Runny Nose Cough Sore Throat Vomitting or diarrhea Fatigue with no explaination General feeling of being unwell Non of the above

In the last 14 days, have you been in contact with someone who has tested positive for COVID 19 or displayed symptoms listed above *

Yes No

In the last 14 days, have you or anyone in your household returned from travelling out of country or the east coast of Canada *

Yes No

Submit

If you answered Yes to any of the questions, we ask that you refrain from attending class until you have been cleared by a physician or self isolated for 14 days. We will be happy to set you up with ZOOM class options until you are able to return to class.

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