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Basecamp Health Attestation: New COVID Prevention Measures

Basecamp Climbing Inc. (“Basecamp”) has implemented this questionnaire for health and safety purposes in order to help prevent the spread of COVID-19. All visitors, members, suppliers and contractors must complete and submit this form to Basecamp within the 6 hours prior to visiting Basecamp’s facilities. 

If your responses to any of the below questions change between the time that you submit this form and any future visits to Basecamp, you agree to contact Basecamp and cancel your visit. 

The information in this questionnaire is being collected solely to determine whether an individual may access Basecamp’s premises and to keep an accurate record of persons on site. This information will not be used for any other purpose.

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
Parent or Guardian's Email Address

Email*

Confirm Email*
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 Information
Do you currently have any of the following symptoms: Fever (a temperature of 37.8 degrees Celsius or higher),Chills, Cough that is new or worsening , Shortness of breath , Sore throat, Difficulty swallowing, Loss of taste or smell, Nausea/vomiting, Diarrhea, Abdominal pain, Runny nose or nasal congestion (in absence of underlying reasons for these symptoms such as allergies, post nasal drip, etc.), Unexplained Fatigue/Malaise, Headache?*
No
Yes
In the past 14 days, have you had a suspected or confirmed case of COVID-19?*
No
Yes
Have you been advised by the Government of Canada, Ontario Public Health, a doctor, or the Ontario Ministry of Health website to self-isolate due to possible exposure to COVID-19*
No
Yes
In the past 14 days, have you travelled outside of Canada?*
No
Yes
In the past 14 days, have you been in close contact* with anyone with a suspected or confirmed case of COVID-19?*
No
Yes

*Close contact means: (1) living with; (2) providing care to; (3) having close prolonged contact with (i.e. within 2 metres) a person when they were ill; or (4) having contact with the person's infectious bodily fluids while not wearing personal protective equipment.

If the answer is "yes" to any of the 5 questions above, Basecamp may deny you access to the premises. 

Declaration: I have read the information above and verify that the representations made by me are accurate and true.*
Yes
No
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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