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Lodge Contact Tracing - 2021-2022

An inherent risk of exposure to COVID-19 exists in any public place. COVID-19 is an extremely contagious disease that can lead to severe illness and death, especially for senior citizens and individuals with underlying medical conditions. By visiting Mount Pakenham, I voluntarily assume all risks related to exposure to COVID-19.

As requested by the Lanark, Leeds, Grenville Health Unit we ask all customers seated in the Lodge complete this information for use only in the event that contact tracing is required.

The use of these premises and facilities and participation in activities on the premises are subject to the conditions set out in the Exclusion of Liability and Assumption of Risks Notice, which is posted throughout the premises. These conditions will affect my legal rights including the right to sue for negligence or breach of contract or breach of statutory duty of care under the Occupiers Liability Act. I HAVE AND/OR AGREE TO READ THE NOTICE CAREFULLY.

I Agree

 

 

First Guest Name

First Name*

Last Name*

Phone*
First Guest Date of Birth*
I certify that I am 14 years of age or older
First Guest Signature*
Second Guest Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Where are you seated in the lodge?
You must select one.*
Time spent at table
Time spent at table*
less than 15min
15-30min
over 30min
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*
I certify that I am 14 years of age or older
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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