Peridance Center COVID-19 Health Screening Survey

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.



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 *
Are you under the age of 18? *
For applicants below 18 years, a Parent/ Guardian will be required. *

Class Information

Time of Class *

Parent/ Guardian Information

Personal Information


Are you vaccinated? *
Have you received a positive COVID test in the past 14 days? *
Have you been in close contact with another person who has received a positive COVID-19 test in the past 14 days or who has had symptoms of COVID-19? *
Were you advised to self-isolate from the health authority within 15 days as of today, or do you have any family members of housemates who were advised to self-isolate within 15 days as of today? *
Do you have any of the following symptoms or have you experienced any of these symptoms in the last 14 days? *
Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19.

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 agree to the terms and conditions
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.