Name *

First Name

Last Name

n the last 14 days have you, or anyone in your household, had any of the following symptoms of COVID-19 listed below, or knowingly been in contact with anyone with these symptoms? *

HIGH TEMPERATURE - this means you feel hot to touch on your chest or back (you do not need to measure your temperature)

CONTINUOUS COUGH - this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)

LOSS OR CHANGE TO YOUR SENSE OF SMELL OR TASTE - this means you have noticed you cannot smell or taste anything, or things smell or taste different to normal

None of the above

Have you, or anyone you live with, tested positive for COVID-19 infection in the past 14 days? (This refers to the test for current COVID-19 infection, not the antibody / immunity test) *

Yes

No

Have you tested positive for COVID-19 infection MORE THAN 14 days ago? (This refers to the test for current COVID-19 infection, not the antibody / immunity test) *

Yes

No

I agree to cancel my booking if I, anyone in my household, or anyone who I have had physical contact with in the last 14 days, develops symptoms for COVID-19 or tests positive for COVID-19 infection. Kaleyard's short notice cancellation policy will NOT apply to COVID-19 related cancellations. The class can rearranged for a later date or alternative class can be booked. *

I agree

I disagree