Canmore Seniors Association Health Checklist / Waiver

1
Date* This field is required.Must select today's date.
Date
Year
Month
Day
2
Name* This field is required.
First Name
Last Name
3
CSA Number* This field is required.You must be a member to participant in CSA activities.
4
Phone Number* This field is required.Required for COVID contract tracing.
Area Code
Phone Number
5
Email
example@example.com
6
COVID-19 Alberta Health Checklist

Alberta Health Services has developed this COVID-19 Alberta Health Daily Checklist to assist activity organizers in reducing the risk of transmission of COVID-19 among attendees. AHS advise that our attendees (CSA members) are to fill out this checklist prior to participating in the intended activity.

If you answer YES to any of the following questions, you cannot participate in any CSA activity or program.
7
Do you have any new onset (or worsening) of any of the following symptoms?* This field is required.Fever / Chills Cough Shortness of Breath / Difficulty Breathing Sore throat / Painful Swallowing Runny Nose / Nasal Congestion Feeling Unwell / Fatigued Nausea / Vomiting / Diarrhea Unexplained loss of appetite Loss of sense of taste or smell Muscle/joint aches Headache Conjunctivitis (commonly known as pink eye)
YESNO
8
Have you travelled outside of Canada in the last 14 days? * This field is required.
YESNO
9
Have you had close unprotected contact (within 6 feet) in the last 14 days with someone who has travelled outside of Canada in the last 14 days and who is ill with COVID 19 symptoms?* This field is required.
YESNO
10
Have you had close unprotected contact (within 6 feet) in the last 14 days with someone who is ill with COVID 19 symptoms? * This field is required.
YESNO
11
Have you or someone from your household been in close unprotected contact (within 6 feet) in the last 14 days with someone who is being investigated or confirmed to be a positive case of COVID 19?* This field is required.
YESNO
12
PLEASE READ CAREFULLY

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal and provincial governments, through their Health Ministries (such as Canada Health and Alberta Health services) recommend social distancing and have, in many locations, prohibited the congregation of large groups of people. The CSA has put in place preventative measures to reduce the spread of COVID-19 at its premises and for its activities. However, the CSA cannot guarantee that you will not become infected with COVID-19. Further, attending at the CSA premises or participating in any CSA activity, could increase your risk of contracting COVID-19.
13
Signature* This field is required.I understand that this assumption of risk and waiver of liability agreement is in addition to, and is not a substitute for, any other documentation, general waiver, or membership registration required to be executed by the CSA. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 if I attend the premises of the CSA or participate in its activities and that such exposure or infection may result in my personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the CSA may result from the actions, omissions or negligence of myself and others, including, but not limited to, CSA directors, employees, volunteers and program participants. I voluntarily agree to assume all of the foregoing risks and I accept sole responsibility for any injury to myself including, but not limited to, illness, personal injury, disability and death, damage, loss, claim, liability or expense of any kind, that I may experience in connection with my attendance at the CSA premises or participation in CSA activities. I hereby release, covenant not to sue, discharge and hold harmless the CSA, its directors, employees, volunteers and participants of and from any claims, including all liabilities, actions, damages, costs or expenses of any kind. I understand that I have given up substantial rights by signing this release, which includes any claims based on the actions, omissions, or negligence of the CSA, its directors, employees, volunteers and program participants, whether a COVID-19 infection occurs before, during, or after participation in any CSA program.
Clear
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.