Covid19-Return Form – Broadway Dance Ireland

Dancer's Name *

Teacher's Name

Do you have symptoms of cough, fever, high temperatures, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? *

Yes
No

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? *

Yes
No

Are you in close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2 metres for more than 15 minutes altogether in 1 day)? *

Yes
No

Have you been advised by a doctor to self-isolate at this time? *

Yes
No

Have you been advised by a doctor to cocoon at this time? *

Yes
No

Please provide details below of any other circumstances relating to COVID-19, not included in the above, which may need to be considered to allow your safe return to class/work.

* If you are unsure whether or not you are in an at-risk category, please check the information at the link below. If your situation changes after you complete and submit this form, please tell management.

PRINT NAME *

Signature *

Do you give consent for Broadway Dance Ireland to hold a name and contact number for contact tracing? *

Yes
No

Have you travelled to any country outside of the Republic of Ireland in the last 14 days? *

Yes
No

Please provide details below if you answered "Yes" above

Parent/Guardian Signature - I hereby sign (on behalf of my child)

Parent/ Guardian Name

Waiver *

I agree with the following statement

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the public health guidelines recommend social distancing, clean hands policy and wearing of face masks for those over 13 years. I further acknowledge that Broadway Dance School has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Broadway Dance School can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, school staff, other school students and their families. I acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my class.

Return To Class

COVID-19 RETURN TO CLASS FORM

Register

Call

087 261 5809

Location

Co. Clare
Doolin,
Miltown Malbay

Co. Galway
Kinvarra

Email

broadway-dance@hotmail.com