Parent Name *

First Name

Last Name

Dancer's Name 1 *

First Name

Last Name

Dancer's Name 2 (if applicable)

First Name

Last Name

Dancer's Name 3 (if applicable)

First Name

Last Name

Dancer's Name 4 (if applicable)

First Name

Last Name

CERTIFICATION *

I hereby certify, represent and warrant as follows: Within the seventy two (72) hours immediately preceding the Date of this Health Declaration Form (“Declaration”), my child/children HAVE NOT:

tested positive or presumptively positive with the Coronavirus or been identified as a potential carrier of the COVID-19 virus or similar communicable illness (“Coronavirus”);

experienced any symptoms commonly associated with the Coronavirus;

been in direct contact with or the immediate vicinity of any person I knew and/or now know to be

carrying the Coronavirus or has been identified as a potential carrier of the Coronavirus.

Within the last fourteen (14) days immediately preceding the Date of this Health Declaration Form (“Declaration”), my child/children HAVE NOTE traveled out of the state of Illinois.