L K DANCING

updated 19/4/2021

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

I/we affirm that ourselves as well as all household members, do not currently have, nor have experienced the symptoms associated with covis-19 within the last 14 days

I/we affirm that I/we, as well as all household members, have not been diagnosed with Covid-19 within the last 30 days and have not knowingly been exposed to anyone diagnosed with Covid-19 within the past 30 days

I/we affirm that I/we, as well as all household members, have not travelled outside the country or to any city considered to be a ''hot stop'' for Covid-19 infections within the past 30-days

I/we have had ore temperature checked on arrival

Initials

Date

I/we agree to each statement above and release L K dancing form any and all liability for unintentional exposure or harm due to Covid-19

Thanks for submitting!