Health Information Questionnaire

Information supplied in this questionnaire by Train Withe Us customers provides a record of health and is used in assessing student’s suitability to attend our classes. These records will be stored in line with Train Withe Us GDPR policy for a maximum of 1 year.

All dance classes are held at Kimberley Parish Hall, Newdigate Street, Kimberley, Nottingham.
Musical Theatre classes are held at The Temple Centre, Nuthall, Nottingham.

Parent/ Guardian Name*
First Last
Email*
Student Name*
First Last
Venue(s) student attends
Class(s) student attends*
Are you, or any one in your household, experiencing any of the following symptoms at present (or have done in the last 14 days)?
Cough*
- Yes
- No
Shortness of breath*
- Yes
- No
Have you recently travelled outside the UK?*
- Yes
- No
If yes, please state which countries?
Please state your date(s) of travel outside of the United Kingdom.
Have you knowingly encountered someone displaying the symptoms of COVID-19 or someone who has tested positive in the last 14 days?*
- Yes
- No
*
- I confirm that the above information is accurate to the best of my knowledge and hereby give consent for the information to be shared with Train Withe Us staff and stored by Train Withe Us. I agree to inform Train Withe Us immediately should any of this information change and will not bring my child to Train Withe Us classes if they or anyone in their household shows any COVID-19 symptoms, tests positive for COVID-19 or has returned to the UK from abroad in the past 14 days. Myself and the student(s) for which I am responsible, agree to comply with all hygiene procedures and rules while present on Train Withe Us sites and understand failure to follow these directives may result in termination of services provided with no refund.

Health Information Questionnaire

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