covid19

Declaration Form

Covid-19 Declaration

Dear Students and Guests,

Given the evolving situation in COVID-19 (Coronavirus Disease 2019), we are taking the necessary measures to ensure the safety and well-being of our visitors, learners, staff and the community. As such, we request that you take a couple of minutes to fill in this form. The information gathered will be useful for contact tracing should the need arise.

For the safety of all, this declaration form will be filled prior to each class.

Thank you for your cooperation.

For your kind information, the following measures are also taken to ensure your well-being in the dance studio:

1. Personal Declaration
2. Hand Sanitisers are readily available
3. Safety Social Distancing
4. One dedicated partner for social dances

Should you have any concerns, please feel free to reach us at dance@shallwedance.sg or 8779 5567

Name*
First Last
Mobile Contact*
Temperature (Degree Celcius)*
Are you feeling unwell or having any respiratory symptoms (such as fever, cough, sore throat or runny nose)?*
- Yes
- No
Have you travelled to and from any country(ies) within the last 14 days?*
- Yes
- No
Within the last 14 days, have you had contact with a COVID-19 (Coronavirus Disease 2019) confirmed case or suspect case, or a person issued Quarantine Order (QO) / Leave of Absence (LOA) / Stay-Home Notice (SHN)?*
- Yes
- No
Are you currently serving Quarantine Order (QO), Leave of Absence (LOA) or Stay-Home Notice (SHN)?*
- Yes
- No
Should you have answered "Yes" to any of the above or have a temperature of more than 37.5 degrees celcius, please share with us more and meet your instructor prior to the start of class.*
Consent and Agreement*
I agree to the terms and conditions of this class
By submitting this form, you agree to provide your personal data prior to your visit/ meeting and understand that the data gathered is solely for contact tracing should the need arise.

I also understand that anyone making false declarations can be prosecuted under the Infectious Diseases Act.

covid19

Covid-19 Declaration

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