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COVID 19 Declaration Form

PLEASE COMPLETE THIS FORM WHEN REQUESTED, IN ADVANCE OF DYT EVENTS

KEEP THESE QUESTIONS IN MIND EACH TIME YOU COME IN AND LET US KNOW IF YOUR SITUATION CHANGES. PLEASE DON’T PUT ANYONE AT RISK IF YOU’RE FEELING UNWELL.

COVID-19 Declaration Form (Questionnaire)

You must complete the following form before attending a DYT event.
Name*
First Last
Age*
Parent / Guardian Consent
Parent / Guardian oversight of this questionnaire is required for participants under 18. Please discuss the questionnaire with your young person and sign below. Thank you!
Parent / Guardian Name*
First Last
Parent / Guardian Contact Phone Number*
QUESTIONNAIRE
If the answer is Yes to any of the below questions, you are advised to stay at home and seek medical advice. There will be other chances to join events at future dates.
Have you visited any countries outside of Ireland (including Northern Ireland) in the last 14 days?*
- Yes
- No
Are you experiencing any flu-like symptoms (cough, fever, high-temperature, sore throat, runny nose, breathlessness) or symptoms of Coronavirus / Covid-19 now or in the past 14 days?**
- Yes
- No
Have you been diagnosed with a confirmed case of, or a suspected case of, Coronavirus / Covid-19 or flu like symptoms in the last 14 days?*
- Yes
- No
Have you been in contact with someone with a suspected or diagnosed case of Coronavirus / Covid-19 in the last 14 days?*
- Yes
- No
Is a member of your household self-isolating?*
- Yes
- No
Are you in a period of self-isolation and/or cocooning under the current Health Policy Rules?*
- Yes
- No
Have you been advised by your doctor that you are in an at risk group?*
- Yes
- No
If yes, please liaise with your doctor (and parent / guardian) re returning to the studio.
SIGNED:*
Today's Date*
DD slash MM slash YYYY
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Dublin Youth Theatre Company Limited by Guarantee is registered
in Dublin, Ireland.

Company Registration No. 153220
Charity Registration No. 2002 8619 - CHY 10897

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