Individual Name *

First Name

Last Name

Individual's Parent/Guardian (if individual is younger than 18 years)

First Name

Last Name

Phone *

(###)

###

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1) I understand the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and COVID-19 is extremely contagious. *

Yes

No

2) I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days OR if such diagnosis was made I, as well as all household members, have been cleared as noncontagious by a Provincial or local public health authority. *

Yes

No

3) I affirm that I (and my child, if the participant is a minor) have not been exposed to a person with a confirmed or suspected case of COVID-19; OR if such exposure did occur, the date of exposure was more than 14 days prior to the date this Declaration was signed. *

Yes

No

4) I affirm that I have not, nor has anyone in my household, experienced any signs or symptoms of COVID-19 in the last 14 days (including fever, new or worsening cough, fatigue, chills and body aches, respiratory illness, difficulty breathing, nausea, vomiting or diarrhea, pink eye, or loss of taste or smell). *

Yes

No

5) If I experience, or if anyone in my household experiences, any signs or symptoms of COVID-19 after signing this Declaration, I (and my child, if the participant is a minor) will immediately isolate, notify the Ritchie Community League, and will not attend any of the Hall’s, activities, programs, events or services until at least 14 days have passed since those symptoms were last experienced. *

Yes

No

6) I affirm I have not, nor has any member of my household, travelled to, or had a lay-over in any country outside Canada, in the past 14 days. *

Yes

No

7) While participating in this activity, program, event or service, I (or my child, if the participant is a minor) will follow the safety, physical distancing, and hygiene protocols of the Ritchie Community League. *

Yes

No

8) I understand the Ritchie Community League may remove me (or my child, if the participant is a minor) from participation in the activities, programs, events or services at any time if they believe I (or my child, if the participant is a minor) have not complied with the terms listed above. *

Yes

No

9) I have carefully reviewed this Declaration, and I fully understand and accept the terms set out above. I further understand I have given up substantial legal rights by signing this Declaration and I have done so voluntarily. By clicking "Submit", I am agreeing to be bound by the terms of this legal document. *

Yes

No

Date *

MM

DD

YYYY