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COVID-19 Self-Declaration Form for Facility Access

Important Note: You are signing this waiver on behalf of your Mental Health Skates with Wave Sports. 

WAVE Sports is excited to have its Members back on the ice. To ensure the safety of our Members, staff, and  community, we ask that you complete this form prior to entering our facilities. Anyone who has not completed the form will be denied access to the facility.

Date: January 20, 2022

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First Player's Name

First Name*

Last Name*
First Player's Date of Birth*
I certify that I am 18 years of age or older
First Player's Information

Instructor Name:

Rental Date:

Rental Time:

Please indicate Yes or No:

1. Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
Cough*
Shortness of Breath / Difficulty Breathing*
Sort Throat*
Runny Nose:*
2. Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
3. Have you or anyone in your household been in contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
4. Are you currently being investigated as a suspect case of COVID-19?*
5. Have you tested positive for COVID-19 within the last 10 days?*
First Player's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
I, confirm that I have reviewed all the information above and my answers are correct on the Self Declaration form. If my health status was to change, I will contact Halton Health immediately.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Instructor Name:

Rental Date:

Rental Time:

Please indicate Yes or No:

1. Do you have any of the below symptoms: 

Fever (greater than 38.0C)*
Cough*
Shortness of Breath / Difficulty Breathing*
Sort Throat*
Runny Nose:*
2. Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
3. Have you or anyone in your household been in contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?*
4. Are you currently being investigated as a suspect case of COVID-19?*
5. Have you tested positive for COVID-19 within the last 10 days?*
Parent or Guardian's Signature*
Electronic Signature Consent*
 1. COVID-19 can be transmitted by asymptomatic people and the statements made by members contained in this document cannot provide certainty that COVID-19 will not be transmitted. The facilities are taking steps to impose and enforce appropriate protocols to keep you and other members safe, but there can be no assurance that COVID-19 will not be contracted. This is a risk that each member must assess themselves, and if you choose to come to the Facilities, you assume the risk of either contracting COVID-19 or transmitting it to others.<br> 2. The Facilities are not responsible for any illness, injury, property damage, expense, loss of income, damage, or loss of any kind suffered by you, including should you contract COVID-19 during, or as a result of, your use of the Facilities, caused in any manner whatsoever including but not limited to, the negligence of the Facilities, its owners, employees, directors and members. <br> 3. You hereby declare that prior to any visit to the Facilities, neither you, or anyone else in your household has experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing). If you or anyone in your household experience any cold or flu-like symptoms after submitting this form, you will not visit the Facilities for a minimum period of 14 days after the cold or flu-like symptoms have completely gone away.<br> 4. You hereby declare that you or any member of your household have not been to, travelled to, visited or had a lay-over in any country outside Canada in the past 14 days. If you or anyone in your household travels to any country outside Canada after submitting this form, you will not visit the Facilities for a minimum period of 14 days after the date of return to Canada.<br> 5. You acknowledge that you have read this Agreement and understand it. You have had the opportunity to review this Agreement and you acknowledge that you have executed this Agreement voluntarily and agree to be bound by this Agreement. You further acknowledge that this Agreement is binding upon yourself, your heirs, spouse, children, parents, guardians, executors, administrators and legal or personal representatives.


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