COVID-19 Renter Screening Questionnaire

First Name *

Last Name *

Phone # *

Email *

1. Do you or does anyone in your household have any of the following symptoms, either new or worsened (if not associated with allergies, chronic or pre-existing conditions) *

fever, chills, cough or worsening chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, and/or muscle aches?

Yes

No

2. Have you come into close contact with someone who has tested positive for COVID-19 or who has been ordered to self-isolate in the past 14 days? *

Yes

No

3. Have you or has anyone in your household returned from travel outside of Canada (including USA) in the past 14 days? *

Yes

No

If you answered “yes” to any of these questions, or if the student is experiencing any of the symptoms listed below after completing the questionnaire, contact the PdA registration desk (604 664 1636 ext. 0) as soon as possible.

If you are an Actor with the Summer Teen Theatre Troupe, email production@placedesarts.ca

Please confirm each of the following: *

I certify that I answered the questionnaire truthfully and to the best of my knowledge or my child(ren)'s current health status.

I acknowledge that Place des Arts follows the appropriate protocols to promote safety and health in their Facilities during the COVID-19 pandemic.

I certify that I have read the Place des Arts Safety Plan dated January 5, 2021 (found on the Policies and Procedure webpage on placedesarts.ca) and acknowledge that I must comply with the plan’s safety measures and protocols.

I certify that I am aware of the continually updating information provided by BC Centre of Disease Control on how to protect myself, my family, and my community and what to do if I suspect that I have COVID-19.

Thank you for your co-operation in keeping PdA a safe space.

Please check your email for the confirmation to show at the Check-In Desk at Place des Arts (PdA) or to your teacher at any authorized satellite site hosting PdA programs.

Note: If the confirmation email does not show up in your email account be sure to check the junk/spam folder.