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COVID Questionnaire

DAILY COVID-19 ATTESTATION AND AGREEMENT 

By signing below, the Participant (named below) or the Participant’s Guardian attests that the Participant: 

  1. Does not knowingly have COVID-19; 
  1. Is not experiencing any known symptoms of COVID-19, such as fever, cough, shortness of breath or malaise; 
  1. Has not travelled internationally during the past 14 days; 
  1. Has not frequented a COVID-19 high risk area in the Province during the last 14 days; 
  1. Has not, in the past 14 days, knowingly come into contact with someone who has COVID-19,  who has known symptoms of COVID-19, or is self-quarantining after returning to Canada; and 
  1. Has been following government recommended guidelines in respect of COVID-19, including practicing physical distancing. 

Furthermore, by signing below, the Participant or the Participant’s Guardian agrees that while attending or participating in the Organization’s events or attending at the Organization’s facilities, the Participant: 

  1. Will follow the laws, recommended guidelines, and protocols issued by the Government of the Province in respect of COVID-19, including practicing physical distancing, and will do so to the best of the Participant’s ability while participating in the Organization’s events or attending at the Organization’s facilities; 
  1. Will follow the guidelines and protocols mandated by the Organization in respect of COVID-19; 
  1. Will, in the event that the Participant experiences any symptoms of illness such as a fever, cough, difficulty breathing, shortness of breath or malaise, immediately: 
  1. inform a representative of the Organization; and 
  1. depart from the event or facility. 

FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 

By signing below, the Participant (named below) or the Participant or the Participant’s Guardian attests that the Participant has been diagnosed with COVID-19, but been cleared as noncontagious by provincial or local public health authorities and has provided to the Organization, in conjunction with this COVID-19 ATTESTATION AND AGREEMENT, written confirmation from a medical doctor of the same. 

Print Name (Participant): _________________________________

DOB (mm/dd/yy): ________________________

Print Name (Guardian): ______________________________

Signature (Guardian): ________________________________

Today’s date (mm/dd/yy): ____________________________

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