Parent Name

Parent Email

Student Name

Branch Location
---Baumgartner Center for Dance/Third WardRiverpoint Village/Fox PointTowne Centre/Brookfield

Class Level
---Above the CloudsCreative MovementPre-Ballet IPre-Ballet IIPre-Ballet IIIBallet IBallet IIBallet IIIBoys Class IBoys Class IIBallet IVBallet VBallet VIBallet VIIPre-AcademyAcademy IAcademy IIPre-Professional Program

Date Of Absence

If multiple days please list all

Reason for Absence
---schedule conflictillnessinjuryother

If you selected "Other" please specify

If you selected "Illness" please specify

Fever or Chills:
YesNo

Cough:
YesNo

Shortness of breath or difficulty breathing:
YesNo

Fatigue:
YesNo

Muscle or body aches:
YesNo

Headache:
YesNo

New loss of taste or smell:
YesNo

Sore throat:
YesNo

Congestion or runny nose:
YesNo

Nausea or vomiting:
YesNo

Diarrhea:
YesNo

Student has sought medical care for COVID-19:
YesNo

Student has tested positive for COVID-19:
YesNo