Pre-Class Screening Form | Open Space Studio, I

PRE-CLASS HEALTH SCREENING

MUST BE COMPLETED BY PARENT/GUARDIAN BEFORE ATTENDING IN-STUDIO CLASSES

Student's Name

Date

Does your child have any of the following symptoms? (check all that apply):

cough?

sore throat?

rapid or difficulty breathing(w/o recent exercise)?

flushed cheeks?

gastrointestinal issues(diarrhea, nausea, vomiting)?

fatigue?

headache?

new loss of smell or taste?

new muscle aches?

None of these

Has the student had contact with someone in the previous 14 days with a confirmed or presumptive diagnosis of COVID-19

Yes

No

Parent/Guardian Digital Signature

Your child's pre-class health screening has been received and added to the studio log.

Thank You.

19R Court Street

Plymouth, MA 02360

(781) 929-7141