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?*

YesNo

If yes please provide date of illness:

Do you the teacher or anyone you have recently been in contact with travelled abroad in the past 14 days?*
YesNo
If yes please provide date of travel and country:

Teacher Name/Surname:*

Class Name/s:*

Email:*

Contact Number:*

Date:*

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.*
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SIGNATURE:*