HEALTH INFORMATION QUESTIONNAIRE

Information supplied in this questionnaire by Inspire Ballet & Dance customers provides a record of health and is used in assessing student’s suitability to attend our course. These records will be stored in line with IB&D GDPR policy for a maximum of 1 year.

Student Name

First Name

Last Name

Parent/ Guardian Name

First Name

Last Name

Class Name(s)

Class day(s) (Mon- Sat)

Date of first class back

Are you, or anyone in your household, experiencing any of the following symptoms at present (or have done in the last 14 days)?

Have you recently travelled outside the UK?

If Yes please state which countries & your date(s) of travel outside the UK.

Have you knowingly encountered someone displaying the symptoms of COVID-19 or someone who has tested positive in the last 14 days?

I confirm that the above information is accurate to the best of my knowledge and hereby give consent for the information to be shared with Inspire Ballet & Dance staff. The student(s) for which I am responsible, and I agree to comply with all hygiene procedures and rules while present on Inspire Ballet & Dance sites and understand failure to follow these directives may result in termination of services provided with no refund.

Should I/my children or any one in my household become unwell with symptoms or any of the above changes, I confirm that I will contact Inspire Ballet & Dance and will not return to the building for the required isolation period under any circumstances.

Our Office

Balham Baptist Church, 21 Ramsden Road
London, England, SW12 8QX
United Kingdom