Please take a moment to fill out this COVID Waiver before dropping your child off at the studio. This waiver needs to be completed weekly. Please contact the studio for further screening if you answer “yes” to any of the questions below. Thank you in advance for your cooperation as we try to keep our families safe!

Name

First Name

Last Name

Child's Name

First Name

Last Name

Today's Date

YYYY

In the past 10 days, has your child experienced fever, a new cough, new loss of taste or smell, or shortness of breath?

In the past 10 days, has your child or anyone in your household tested positive for COVID-19?

In the past 14 days, has anyone in your household been in close contact wth anyone that tested positive for COVID-19?

In the past 14 days, has anyone in your household traveled internationally or returned from a state identified by New York as having having widespread community transmission of COVID-19?

Positions Dance Studio, Inc. 264 Deer Park Avenue * PO Box 612 * Babylon, NY 11702 631-669-8612 kelly@positionsstudio.com Privacy Policy

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COVID-19 Waiver