Loading...

COVID-19 Self-Declaration Form for Facility Access.

Important Note: The Jr Raiders Hockey Club is requesting each family to complete 1 waiver that covers your child for the 2021-22 season.  If you should contract 1 or more symptom as asked below, you are not permitted into any Wave Sport facility. We ask that each families acts responsible day to day and informs Kristen Cleary in writting by email (kcleary@raiderssports.ca), IF your childs health status changes as it relates to Covid-19.

Jr Raiders Hockey Club  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: November 27, 2021

Please select who will be participating...
AdultMinor
Continue
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

Team Name:

Game Time:

Please indicate Yes or No:

1. Do you have any of the below symptoms: 

Are you sick with a cold/flu or are you displaying any signs of COVID-19 and/or flu-like symptoms?*
Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?*
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*
Have you been identified by Public Health as a close contact of someone with COVID-19?*
Have you been told to isolate by Public Health 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?*
Ontario Residents only: In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?*
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

Team Name:

Game Time:

Please indicate Yes or No:

1. Do you have any of the below symptoms: 

Are you sick with a cold/flu or are you displaying any signs of COVID-19 and/or flu-like symptoms?*
Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?*
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*
Have you been identified by Public Health as a close contact of someone with COVID-19?*
Have you been told to isolate by Public Health 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?*
Ontario Residents only: In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!