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COCHRANE & DISTRICT AGRICULTURAL SOCIETY
Box 897, Cochrane, Alberta, T4C 1A9
Ph: 403-932-3250 Cell:403-909-3250
Email: ​cochraneagsociety@gmail.com​ www.cochraneagsociety.com

APPENDIX TO WAIVER DURING CURRENT HEALTH CRISIS

For the safety of all our members, passholders and user groups, we ask you to complete this self-declaration form before attending activities at the Ag Society Park

Today's Date: July 4, 2020

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
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*

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
I understand the risk of coming in contact with other people during the COVID-19 global pandemic at the Ag Society Park and that I could become infected with COVID-19 while at the Ag Society Park.*
No
Yes
I agree and assume all risk and release and absolve Cochrane BMX and the Cochrane & District Agricultural Society and its affiliated officials, volunteers, offices, directors, agents, representatives and employees and the owners and occupiers of the land upon which the activity is held, from all responsibility, liability or claims I may have arising from participating in an in person activity at the Ag Society Park during the COVID-19 pandemic*
No
Yes
To your knowledge have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 within the last 14 days?*
No
Yes
Are you experiencing any cold or flu-like symptoms, including, but not limited to fever, cough, sore throat, runny nose, respiratory illness, headache, loss of taste or smell, shortness of breath or difficulty breathing?*
No
Yes
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 14 days?*
No
Yes
I understand that should such above mentioned circumstances arise I have a duty to Cochrane BMX and to the Cochrane & District Agricultural Society to not join any in person activities at the Ag Society Park for a period of 14 days. Upon re-entry I will be required to complete a further self-declaration.*
No
Yes
I have read, understood and will abide by the protocols sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
I have read, understood and will abide by the reactivation plan sent out by the Cochrane & District Agricultural Society and Cochrane BMX*
No
Yes
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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