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COVID-19 Screening Form

Please complete the self-screening form on the day of your booked climbing session within 12 hours before visiting. This must completed for every visit. If you have symptoms or have answered "yes" to any of the following questions, please call (416) 672-0239 to cancel your session and stay home. We require your contact information in the event contact tracing is needed.

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

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

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

COVID-19 symptoms
  • Fever
  • New or worsening cough
  • Shortness of breath
  • Sore throat
  • Headache
  • Runny nose or nasal congestion (in absence of underlying reason for these symptoms such as: allergies or post nasal drip)
  • Change or loss of taste/smell
  • Nausea/vomiting, diarrhea, abdominal pain


Do you have any of the follow symptoms listed above?*
No
Yes
Have you returned from travel outside of Canada in the last 14 days WITHOUT a quarantine exemption?*
No
Yes
Have you had any close contact (without PPE) with a known COVID positive person in the last 14 days?*
No
Yes
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*
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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