Email Address:

Full name (of dancer, staff or person entering The Dance Zone:

Phone Number:

Date:

Participant's Temperature Today (indicate C or F):

Have you experienced any of the following symptoms in the last 24 hours ?:

Have you had close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days?:

YesNo

Have you or anyone in your household tested positive for COVID-19 in the last 14 days?:

YesNo

Have you or anyone in your household recently been tested for COVID-19 and are awaiting results?:

YesNo

Have you or anyone in your household had close contact with anyone with a confirmed or probable diagnosis of COVID-19 or who is being tested for COVID-19 within the past 14 days?:

YesNo

A copy of your responses will be emailed to the address you provided.

Email Address

Weston Road COVID-19 Health Screening Questionnaire

A copy of your responses will be emailed to the address you provided.

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