Name *

First Name

Last Name

Within the last 10 days have you been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19?

Yes

No

Within the last 10 days have you tested positive for COVID-19, waiting for COVID-19 test results, or has any heath department or healthcare provider advised you to quarantine?

Yes

No

Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem)?

Yes

No

Please check the box if you have experienced ANY of the following symptoms within the last 10 days:

Fever

New Cough

Chills

New loss of taste/smell

Shortness of breath or difficulty breathing

New rashes or lesions

Nausea or vomiting

Diarrhea

Headaches

Runny nose/nasal congestion without other known cause

NONE OF THE ABOVE

Within the last 10 days, have you traveled outside of the country?

Yes

No

I agree to properly wear a mask during the entirety of my voice lesson.

I agree

I agree to have my temperature taken upon entering the voice studio.

I Agree

Shacara West cannot guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others. I voluntarily seek services provided by Shacara West and understand that I am increasing my risk of exposure to the Coronavirus/COVID-19. I will comply with all set procedures to reduce the spread while attending my in-person voice lesson.

I Agree

I understand that failure to comply with the outlined COVID-19 procedures while in my voice lesson with Shacara West and/or display of previously listed symptoms will result in my needing to reschedule my lesson.

I understand