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ICanDance!

Covid-19 Health Screening

Declaration

How are you feeling today?

First Name

Last Name

Email

I (and/or my child) am not experiencing these symptoms: fever, sore throat, muscle aches/fatigue, cough/worsening chronic cough, difficulty breathing, loss of sense of taste or smell, nausea, vomiting, diarrhea, headache, loss of appetite.

In the last 14 days, I (and/or my child) have not been advised to self-isolate or quarantine at home by Public Health or Border Services.

I (and/or my child) haven’t been in close contact with a Covid-19 patient in the last 14 days. "

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

ICanDance! ®

North Vancouver . West Vancouver, British Columbia, Canada

Tel 604-379-2046

Email: ms.marni@icandance.ca

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COVID Health Screening Declaration

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ICanDance! respectfully and humbly acknowledges that our work and residence are on the unceded lands of the xʷməθkʷəy̓əm (Musqueam), Sḵwx̱wú7mesh (Squamish), and səl̓ilwətaɁɬ (Tsleil-Waututh) Nations.