Covid Questionnaire

Name *

First

Last

Email *

Do you have a fever? *

Do you have a cough? *

Do you have difficulty breathing? *

Do you have a sore throat or difficulty swallowing? *

Do you have a runny nose? *

Do you have loss of taste or smell? *

Are you not feeling well? *

Do you have nausea, vomiting or diarrhea? *

Have you or anyone in your family returned from travel outside Canada in the past 14 days? *

NOTE:

Phone

Creating a generation of artists who have no fear in enhancing their skills and exploring their creativity!
-Revival Dance Company

STAY CONNECTED

165 Matheson Blvd E Unit 10 Mississauga,
ON L4Z 3K2

905-238-6616

info@revivaldance.ca