COVID-19 Screening & Waiver


    COVID-19 Screening & Waiver


    ENTRY IS NOT ALLOWED WITHOUT SIGNATURE AND MUST BE COMPLETED
    BEFORE ***Entry


    Incomer Name
    (If a Child, Please fill in the format, "Child Name/ Parent Name"):
    Purposes:
    Body Temperature Reading:
    Degrees Celsius;
    Anyone with Fever (=>38) will not be
    allowed entry.


    Standard Covid-19 Screening Questions
    (Required by the Ontario Ministry of Health and Toronto Health Unit)


    Q1) ARE YOU/ IS YOUR CHILD/ ANYONE IN THE SAME HOUSEHOLD/ ANY CLOSE RELATIVE experiencing any of the Covid-19 symptoms, including – fever, dry, cough, shortness of breath or difficulty breathing?



    Q2) HAVE YOU/ HAS YOUR CHILD/ ANYONE IN THE SAME HOUSEHOLD/ ANY CLOSE RELATIVE come in contact with anyone experiencing any of the Covid-19 symptoms or with a confirmed Covid-19 test or are waiting for results from a Covid-19 test in the past 14 days?



    Q3) HAVE YOU/ HAS YOUR CHILD/ ANYONE IN THE SAME HOUSEHOLD/ ANY CLOSE RELATIVE travelled outside of Canada/ arrived Canada in the last 14 days?



    Q4) DO YOU/ DOES YOUR CHILD/ ANYONE IN THE SAME HOUSEHOLD/ ANY CLOSE RELATIVE have any plan travelling outside of Canada/ arriving Canada in the near future?



    Travelling Outside of Canada


    Departure Date:


    Arrival Date:


    Arriving In Canada


    Arrival Date:


    (Please note that ANY STUDENT involved in Q3 & Q4 situations (IF YES), must quarantine for 14 days and must not attend any classes at LPR)


    Please Initial:



    I understand COVID-19 is currently a Pandemic and has a long incubation period during which carriers of the virus may not show any symptoms. I understood and I/ my child will comply with the related La Pirouette Royale COVID-19 Health & Safety Protocols and respect required Physical Distancing. I understand this document will be kept in a Screening Document Folder. I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to attend classes/ let my child attend classes for the time being.


    NAME PRINTED:


    Signed:



    For (Child Name):

    526 McNicoll Ave

    North York, ON M2H 2E1

    416.900.3084

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    info@lapirouetteroyale.com