COVID 19 – INFORMED CONSENT

Please find below Samantha Walsh Pole Dance and Fitness’s safety statement with regards to Covid-19. Please sign to say that each time you attend the studio, you agree to the following.

To the best of my knowledge, I:

  
 Have not shown any symptoms of Covid-19 in the past 14 days. According to the NHS and Gov.UK, below are the main symptoms: High temperature new, continuous cough, loss or change to your sense of smell or taste.
 Have not been in contact with anyone who has tested positive for Covid-19 or shown any of the above symptoms in the past 14 days.
 Have worn a protective mask when in public situations where social distancing is not consistently possible.
 Understand I could be a carrier of Covid-19 and be asymptomatic.
 Understand that I could contract Covid-19 from an asymptomatic person at our studio or from a contaminated surface at our studio.
 Am fully aware of the studio’s safety procedures (posted on our website) to prevent the spread of Covid-19 and will follow these procedures.
 Agree to inform the studio immediately if I have developed symptoms within a two week period of being in the studio, or if I have learned that I have been in direct contact with someone who has later tested positive for Covid-19 within the same two week period or travelled in the last 14 days to a Covid-19 risk area.
 Agree to inform the studio of any allergies that I may have to cleaning products, PPE or similar that may be used at this time and may adversely affect my health.
 Agree that my data provided on this form can be used to contact me if I have been in a class with a person that has developed symptoms or has been in direct contact with somebody who has later tested positive for Covid-19.
 Understand that if I willfully and intentionally violate the stated hygiene policy and social distancing policy in our studio, the studio has the right to immediately remove me from class and suspend me from attending any future classes, without a refund.
 Agree to inform the studio immediately if I learn that any of the above information changes or I obtain new information.

Please sign on behalf of your child if under 16 years of age.

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