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This mandatory waiver is for the purpose of Covid 19 safety to clients, staff and our wellness centre.

1. I do not have a fever.                   

2. I do not have any of the following symptoms:         

     a) New onset of cough                                   

     b) Worsening chronic cough                          

     c) Sore Throat                                                        

     d) Shortness of breath                                            

     e) Difficulty breathing                                               

     f) New loss or decrease in sense of taste or smell   

     g) Runny nose                                                     

     h) Non allergic sneezing                                        

3. I haven't travelled or haven't had close contact with anyone who has travelled in the past 14 days.    

4. I haven't had any close contact with anyone with a confirmed or suspected case of Covid 19.          

5. When I was in close contact with someone that had Covid 19 or suspected to have it, I wore the required or recommended PPE (gloves, mask, gown, goggles or N95 with aerosol generating medical procedures).

 

 

First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Middle Name

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Middle Name

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Middle Name

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Middle Name

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Middle Name

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Middle Name

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Middle Name

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Middle Name

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Middle Name

Last Name*
Tenth Clients Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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