Peridance Center COVID-19 Health Screening Survey

Are you taking a dance class with us in-person?

All registrants are required to fill out a health screening survey per class within an hour prior to arrival at Peridance. Students will not be allowed to enter the building until they have completed a COVID-19 Health Screening Survey.

- This questionnaire is to comply with the 'Prevention Guidelines of Infectious Diseases for Peridance Center' and is collected from all dancers/students.
- If you make false information or deliberately omit or conceal facts, you may be subjected to penalties or fines.
- You may be restricted from taking a class depending on the responses.
- The collected personal information is used only for epidemiological tracing in the event of a confirmed patient.

Policy

Masks:

Peridance requires all persons to wear masks while in this partnering class regardless of vaccination status or living situation. This is a partnering class therefore we are requiring masks for the time being. Peridance will not accept bandanas, t-shirts or other garments tied around the face, or gaiter neck wraps as appropriate mask coverings, as they are not secure and may fall while dancing. I understand and agree that if I do not arrive at Peridance with an approved mask (no gaiter wrap, no bandana, no t-shirt or other garment tied around face), I will not be allowed to enter the building. I understand that if I arrive at Peridance without a mask that I will forfeit my place in class and that I will not be reimbursed or given credit for the class.

I am *

a staff member

a Peridance Center faculty member

a program student

a drop-in student

Are you under the age of 18? *

Yes

For applicants below 18 years, a Parent/ Guardian will be required. *

Yes, I am the Parent/ Guardian

Class Information

Name of Class *

Date of Class *

Time of Class *

Parent/ Guardian Information

Parent/ Guardian First Name *

Parent/ Guardian Last Name *

Parent/ Guardian Email *

Parent/ Guardian Phone *

Personal Information

First Name *

Last Name *

Date of Birth *

Phone *

Email *

COVID-19 Liability Release Waiver

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions which Peridance Center, LLC. (the "Organization") adheres to comply.

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that Peridance Center LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.

I further acknowledge that Peridance Center LLC can not guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Peridance staff, faculty, and other studio clients, students, and their families.

I voluntarily choose to study, work, and/or dance at Peridance Center LLC and acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while at the Center.

I attest to my answers stated above in the survey.

I hereby release and agree to hold Peridance Center LLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Peridance, or that may otherwise arise in any way in connection with any services received, time worked or studied at Peridance Center LLC. I understand that this release discharges Peridance Center LLC from any liability or claim that I, my heirs, or any personal representatives may have against Peridance Center LLC with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to my entering Peridance Center today. This liability waiver and release extends to Peridance Center LLC together with all owners, partners, and employees.

Participant's Full Name *

Today's Date *

Participant's Signature

Clear

I agree to the terms and conditions

Parent's Full Name *

Today's Date *

Parent's Signature *

Clear

I agree to the terms and conditions

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.

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