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: ConsultationStudent ClassesTeaching StaffOthers 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? YesNo 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? YesNo 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? YesNo 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? YesNo 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):
