THE NATIONAL BALLET CONSERVATORY HEALTH DECLARATION

Due to the 2020 Outbreak of the novel Coronavirus COVID-19 The National Ballet Conservatory is taking extra precautions to ensure the care of every student. If you have been exposed to COVID-19 you may spread the disease to The National Ballet Conservatory teachers, staff and other students. Therefore prior to attending each lesson you are requested to complete and sign this form to reduce contagion.

Do you the teacher, or any anyone you have recently been in contact with have any of the following symptoms?*

FeverCoughShortness of breath/Trouble breathingOther symptomsNo symptoms

Do you the teacher, or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19?*

Do you the teacher or anyone you have recently been in contact with travelled abroad in the past 14 days?*

YesNo

I herby confirm that I have advised The National Ballet Conservatory of any other place of work, study or group activity I have attended since my last day of work for NBC.*

SIGNATURE:*