Declaration Form (Covid Safe Venue)

Name :*

Surname:*

Name, Surname of child (if applicable):

E-mail :*

Confirm E-Mail:*

Mobile Number (of student or if applicable of the responsible parent or adult to be reached on the day):*

Confirm Mobile Number:*

Are you filling this form out on behalf of your child? If yes please note that, I, from here on refers to your child who you are responsible for:*

I confirm I am not vulnerable or at risk:

I confirm no one in my household is vulnerable or at risk:

I have read, understood and will follow all the venues instructions and their H&S:

I agree to wear a face mask or visor and know how to use these (or requested a screen if you cannot wear one):

I have read and will follow the social distancing rules at all times (min 2m for singing, min 1m for piano lessons):

I declare and confirm I have not had any symptoms outlined in the policies within the last 14 days:

I have consulted everyone in my household and confirm no one had any symptoms outlined in the policies within the last 14 days:

I declare and confirm I have not been in close contact to anyone that had any symptoms outlined in the policies within the last 14 days:

I will contact Eximo immediately if I or someone in my household or anyone I'm in close contact with after sending this form develops symptoms:

I have made a note of the procedures, items to take and am prepared for the lesson:

I have read and agree to the general T&C's:

Whilst risk has been assessed and mitigated as much as possible, there is still a risk of infection. I confirm I am happy to take this risk:

I am happy to take the remaining risk of infection and waive any rights to make Eximo responsible for any infection

Check you have filled out all the asterisked boxes, otherwise you will receive an error message:

declaration form PLEASE FILL OUT THE FORM and make the payment at least 48 hrs BEFORE YOUR LESSON