Updated 23/09/2021

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Phone number

I/we affirm that ourselves as well as all household members, do not currently have, nor have experienced the symptoms associated with Covid-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 14 days and have not knowingly been exposed to anyone diagnosed with Covid-19 within the past 7 days.

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

I/We understand that L K Dancing cannot be held liable for any exposure to the Covid-19 Virus caused by misinformation on this form or health history provided by each client.

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!

L K DANCING

Updated 23/09/2021

Covid-19 Health Declaration