Return To Class/Work’ Declaration – Carrigaline Performing Arts

We have been guided by the HSA ‘Return to Work’ form in preparing these questions. To help prevent the spread of COVID-19 in our studios, every student (Parent for those under 18yrs of age) must complete this form before returning to Carrigaline Performing Arts. Every question must be answered below before returning to class. We appreciate your understanding in this matter, so thank you!

RETURN TO CLASS

Carrigaline Performing Arts 'Return to Class Declaration

Student Name*
Parent Name (for those under 18 years)*
Email address
Date*
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, flu-like symptoms or loss of change to your sense of smell or taste now or in the past 14 days?*
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?*
Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (e.g . less than 2 meters for more than 15 minutes altogether in 1 day)?*
Have you been advised by a doctor to self-isolate at this time?*
Please provide details below of any other circumstance relating to COVID-19, not included in the above, which may need to be considered to allow your safe return to class/work.*
Do you take yourself to be responsible for limiting the spread of infection while engaging in Carrigaline Performing Arts activities which will include good hand and respiratory hygiene.*
Have you traveled to any country outside of the Republic of Ireland in the last 14 days? Please provide details below if you answered yes.*
Details of where and when you travelled outside of the Republic of Ireland in the last 14 days (if any)

Should your situation change after you complete and submit this form please inform Carrigaline Performing Arts at your earliest convenience.