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Consent Form
Consent Form
Please fill out the following health declaration form in order to participate in our activity.
If your child is enrolled in an academy class, please fill in the details on his / her behalf.
First Name
Last Name
Mobile Number
Email
Date
Is the building where you live a Covid Containment Zone? If YES please inform our staff immediately on the telephone +91 98202 13156 as we will likely have to cancel your participation / enrollment.
Yes
No
Have you been in close contact with a person / group of people suspected to have COVID-19? If YES please inform our staff immediately on the telephone +91 98202 13156 as we will likely have to cancel your participation / enrollment.
Yes
No
Have you had any of the following symptoms over the past 21 days? Please tick all that are applicable or NONE if you have had NONE of these symptoms over the past 21 days
None
Fever
Cough
Runny / Block Nose
Difficulty in Breathing
Sore Throat
Sudden Body Aches
Diarrhea
Loss of Taste / Smell
I agree to the Covid-19 Consent form.
View Covid-19 Guidelines
I agree to the Indemnity Clause
View Indemnity Clause
Your Signature
Clear
Submit
Thanks for submitting!
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