Health Information Questionnaire | Surrey Youth Theatre

Information supplied in this questionnaire 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 Surrey Youth Theatre’s GDPR policy for a maximum of 1 year.

Parent/ Guardian Name:*

Student Name:*

Emergency Contact Telephone Number One:*

Emergency Contact Telephone Number Two:

Any change of student details e.g medical information or address:

Are you, or anyone in your household, experiencing any of the following symptoms at present (or have done in the last 14 days)?

A new continuous cough*

Yes
No

A high temperature*

Yes
No

A loss of, or change in, your normal sense of taste or smell*

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 UK

Have you knowingly encountered someone displaying the symptoms of COVID-19 or someone who has tested positive in the last 14 days?*

Yes
No

Do you give permission for your information to be shared if required with the NHS Test and Trace to help stop the spread of Coronavirus?*

Yes
No

I, the undersigned confirm that the above information is accurate to the best of my knowledge and hereby give consent for the information to be shared with Surrey Youth Theatre staff.
The student(s) for which I am responsible and I agree to comply with all hygiene procedures and rules while present at Surrey Youth Theatre classes and understand failure to follow these directives may result in termination of services provided with no refund.
I understand that if the student for which I am responsible, or anyone in our household develops any of the above symptoms, at any point during the term, the student will not attend class.

Date*

Print Name*

First Last

Signature*