Covid 19 declaration

To help ensure the safety of all attendees at ClarkeArt camps, workshops and classes, please fill in the below form on behalf of your child. The form will be provided to all and once completed will be filed by ClarkeArt for a period of 6 months. Attendees should inform us if there are any other circumstances relating to COVID-19, not included in the form, which may need to be disclosed to allow their safe attendance.

Student's Name(required)

Class attendance date(required)

Parent's name(required)

Parent's email(required)

Parent's mobile number(required)

Address(required)

I do not have any symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days.(required)

I have not been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days.(required)

I have not been advised by a doctor to self-isolate or cocoon at this time.(required)

I agree that the details on this form may be shared with the HSE in the event that they may be required for the purposes of contact-tracing.(required)

I have read and agree with the Clarke Art terms and conditions.(required)

When on the Clarke Art premises you are required to adhere to our standard policies and procedures regarding infection control of COVID-19, i.e. hand washing/hand sanitising and general coughing/sneezing etiquette at all times. Please states that you agree to this.(required)

Yes No

Do you have any allergies, phobias, conditions or special needs?.(required)

Yes No

If you answered 'Yes', please supply details

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