Covid-19 Test & Trace Form
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is considered extremely contagious and is believed to spread mainly from person-to-person contact. As a result, local governments and health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. Makerfield Ju-Jitsu Academy has put in place preventative measures to reduce the spread of COVID-19; however, MJJA cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Dojo could increase your risk and your child(ren)’s risk of contracting COVID-19. Students under the age of 16 must have a parent complete this form on their behalf. We are collecting this information in-line with government regulations to prevent the spread of COVID-19. Your information will stay confidential.
I am under the age of 16 and this form will be completed by Parent/Guardian?
Date of Birth
Address Line 1
Address Line 2
Date & Time of your attendance
Have you had any COVID-19 symptoms: Fever (over 38 degrees), dry cough or shortness of breath?
Have you been exposed to anyone with COVID-19 OR someone who has had symptoms in the last 4 weeks?
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infectedby COVID-19 by attending MJJA and that such exposure or infection may result inpersonal injury, illness, permanent disability, and death.
I understand that the risk of becoming exposed to or infected by COVID-19 at the Dojo may result from the actions, omissions, or negligence of myself and others, including, but not limited to, MJJA employees, volunteers, and program participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with mychild(ren)’s attendance at MJJA or participation in MJJA programs.
On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless MJJA, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of MJJA ,its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any MJJA / WJJF program.
I agree that all information provided is correct. I consent for Makerfield Ju-Jitsu Academy to pass on any details with regards to test & trace, should it help the government and NHS prevent the spread of COVID-19.
By completing this form you are agreeing that you are abiding by UK Government Covid-19 laws.
You also agree that you will follow ALL measures taken by the club including keeping your distance of 1m and to give consent that ALL details provided on this form will be stored for a period of 21 days after which it will be deleted.
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