TKO Proof of C-19 Vaccination or Negative Test

TKO PROOF OF COVID-19 VACCINATION OR NEGATIVE TEST FORM
Updated JANUARY 1ST, 2022

The purpose of this form is to support the implementation of Trailkeepers of Oregon’s COVID-19 Vaccination Policy. The intention of this policy is to take all possible steps to prevent the spread of COVID-19, in order to protect the health and safety of all of our employees, volunteers, visitors, and the communities we serve. TKO’s newly adopted COVID-19 Vaccination Policy requires that proof of vaccination or a valid negative test be submitted prior to in-person activities starting January 15th, 2022. Please see policy for further details.

By signing below, I acknowledge and accept the conditions of service as outlined in the above and referenced documents.

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First Participant's Name

First Name*

Last Name*

First Participant's Age Acknowledgment*

First Participant's Date of Birth*

I certify that I am 18 years of age or older

First Participant's Information

TKO staff member or volunteer must submit a digital copy of the front of their CDC (or healthcare provider) COVID-19 Vaccination Record: Originals, copies or photographs on a mobile device are acceptable.

I attest to have received a full course of a COVID-19 vaccine (i.e., two shots of either the Pfizer or Moderna vaccines, a single shot of Johnson & Johnson vaccine, or any other FDA-approved). vaccines)

I attest to have received a COVID-19 booster shot.

If not vaccinated, every TKO staff and volunteer must submit a digital copy of a negative COVID-19 test result. Viral tests, including nucleic acid amplification tests (NAATs) and antigen tests, are accepted.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Digital copy of either 1.) CDC COVID-19 Vaccination Record Card OR 2.) negative test result must be in the form of written documentation (paper or digital copy). For a valid negative test result, documentation must include: • Type of test (indicating it is a NAAT or antigen test) • Entity issuing the result (e.g., laboratory, healthcare entity, or telehealth service) • Sample collection date • A negative test result must show the sample was taken no more than 1 day before the event. • A positive test result for documentation of recovery from COVID-19 must show the sample was taken within the 90 days before the event. • Information that identifies the person (full name plus at least one other identifier such as date of birth or passport number) • Test result *

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

First Participant's Signature*

Type Signature

Draw Signature

Click to Sign

Second Participant's Name

First Name*

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Third Participant's Name

First Name*

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Fourth Participant's Name

First Name*

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Fifth Participant's Name

First Name*

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Sixth Participant's Name

First Name*

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Seventh Participant's Name

First Name*

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Eighth Participant's Name

First Name*

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Ninth Participant's Name

First Name*

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Tenth Participant's Name

First Name*

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Parent or Guardian's Email Address

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

PARENT OR GUARDIAN’S AUTHORIZATION FOR PROOF OF VACCINATION OR TESTING RESULTS, READ CAREFULLY I as a parent or legal guardian hereby grant permission for this child to do volunteer work and attest to their full vaccination or negative test results. My signature below hereby represents that I have read, understand, and consent to this agreement.

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*

Parent or Guardian's Age Acknowledgment*

Parent or Guardian's Date of Birth*

I certify that I am 18 years of age or older

Parent or Guardian's Information

I attest to have received a COVID-19 booster shot.

I attest to having a negative NAATs test once per week.

I attest to having a negative antigen test 24 hours before each event to attend.

Valid file types: JPG, GIF, PNG, and PDF

Date of 1.) most recent vaccination shot administered OR 2.) sample collection date of confirmed negative test result. *

Parent or Guardian's Signature*

Type Signature

Draw Signature

Click to Sign

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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