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COVID-19 PERSONAL HEALTH ATTESTATION

 

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and COVID-19 is extremely contagious. BC Wheelchair Sports Association has put in place preventative measures to reduce the spread of COVID-19 however participating in the activity may increase my risk of contracting COVID-19. 

I Agree

I confirm that I have read and signed the BCWSA Declaration of Compliance and agree to the terms as outlined. I understand that if I am unable to adhere to the conditions of the declaration that I am not permitted to enter BCWSA facilities or participate in BCWSA activities, programs or services. 

I Agree

I confirm that prior to attending this training session I have screened myself and I am NOT experiencing ANY of the symptoms of COVID-19 identified by BC Provincial Health Services listed below. 

  • Fever 
  • Cough 
  • Sore Throat 
  • Loss of Sense of Smell
  • Muscle Aches
  • Loss of Appetite
  • Chills
  • Shortness of Breath 
  • Painful Swallowing 
  • Headache 
  • Fatigue 
  • Stuffy or Runny Nose 


I confirm that I am not currently positive for the novel coronavirus. 

I Agree

I confirm that I am not waiting for the results of a test for the novel coronavirus. 

I Agree

I confirm that neither I nor anyone I live with has not come in contact with anyone who is currently being tested for COVID-19, or has tested positive for COVID-19 within the past 14 days.

I Agree

I verify that I have not returned to BC from any country outside of Canada in the past 14 days. I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Provincial Health Services require self-isolation for 14 days from the date a person has returned to Canada. 

I Agree

I confirm that neither I nor anyone I live with has been asked to self-isolate or self-quarantine. 

I Agree

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Provincial Health, the Communicable Disease Control or any other governmental health agency. 

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's COVID-19 Status
Have you been previously diagnosed with COVID-19?*
Yes
No
FOR PARTICIPANTS WHO HAVE BEEN DIAGNOSED WITH COVID-19 - I attest that I have been diagnosed with COVID-19, but have been cleared as noncontagious by provincial or local public health authorities and have provided to the Organization, in conjunction with this Health Attestation, written confirmation from a medical doctor of the same.*
I Agree
I have not previously been diagnosed with COVID-19
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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