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Dance Studio COVID-19 Release Survey Form
Please take a few moments to complete this survey
1
Step 1
2
Step 2
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Age of Consent :
Yes
No
N/A
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What and With Whom are you learning:
Latin Dance with Furor
Belly Dance with Nrityakosh
Ballet with The Lewis Foundation
Others
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Please specify:
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COVID-19 Common Symptoms, as per WHO
. Fever
. Dry Cough
. Tiredness
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I agree to the following:
I understand the aforementioned COVID-19 symptoms.
I affirm that neither I, nor any member of my household, currently has or has experienced the aforementioned symptoms within the past 14 days. Furthermore, I will immediately inform Furor and discontinue classes if I, or any member of my household, d
I affirm that neither I, nor any member of my household, has been diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform Furor and discontinue classes if I, or any member of my household, is diagnosed with COVID-19.
I affirm that neither I, nor any member of my household, has knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform Furor and discontinue classes if I, or any member of my household, i
I affirm that neither I, nor any member of my household, has traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30 days. Furthermore, I will immediately inform Furor and discontinue cl
I understand that the Furor cannot be held liable for any exposure to the COVID-19 virus caused by any misinformation on this form or the health history provided by each Student.
Any legal disputes with the Furor will be subject to Bangalore Jurisdiction
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Next
Our instructors and staff will…
. Do a temperature check before entering the studio, and ensure that it is below 38.0°C.
. Clean/Disinfect frequently touched surfaces thoroughly and at regular intervals
. Wash/Sanitize our hands before and after each session.
. Accommodate a limited number of students in each class to ensure physical distancing.
. Provide sanitizers in the reception area and other locations within the premises.
We are requesting that each of our students, please…
. Allow us to check their temperature before entering the premises to ensure it is below 38.0°C.
. Wear a face mask at all times within the building and within the studio.
. Carry their own bottle or cup for drinking water.
By signing below, I agree to each statement above and release Furor from any and all liability for the unintentional exposure or harm due to COVID-19.
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Student's Name in Full :
*
First Name
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Last Name
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Email Id:
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Please Enter the Valid Email Address
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Mobile Number :
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Invalid phone number.
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Signature:
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Date of Submission:
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The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
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