COVID-19 Questionnaire and Waiver
Parent/Legal Guardian must sign this agreement and complete the below screening process the morning of the first day of the program (before entering camp). Please contact CISV Jacksonville Risk Manager Cathy McQuade at 904 607 4813 if your child tests positive for Covid-19 or shows these symptoms during the program or within 3 days after the program ends.
COVID-19 QUESTIONNAIRE
Name of Youth Participant
First Name
Last Name
Phone number of Parent or Youth Participant
Please enter a valid phone number.
Format: (000) 000-0000.
1. Has the camp participant been around someone who has tested positive for COVID-19 in the past 14 days?
Yes
No
2. Does the camp participant have a temperature of 100.4F or higher taken by mouth?
Yes
No
3. Has the camp participant had shortness of breath at rest or while being inactive?
Yes
No
4. Does the camp participant have a cough that is new or a change in their cough that is different from their baseline if they are asthmatic?
Yes
No
5. Does the camp participant have a sore throat?
Yes
No
6. Does the camp participant have diarrhea?
Yes
No
7. Does the camp participant have chills or repeated shaking with chills?
Yes
No
8. Does the camp participant have muscle aches?
Yes
No
9. Does the camp participant have a headache?
Yes
No
10. Does the camp participant have nausea or vomiting?
Yes
No
9. Does the camp participant have new loss or taste or smell?
Yes
No
9. Does the camp participant have a headache?
Yes
No
Type option 3
Type option 4
The safety of our program participants is critical. If you answered yes to any of these questions, we ask that you do not bring your child to the program.
I agree to contact CISV Jacksonville Risk Manager Cathy McQuade at 904 607 4813 if my child tests positive for Covid-19 or shows the symptoms listed in the questionnaire above during the program or within 3 days after the program ends.
Yes
Assumption of the Risk and Waiver of LiabilityRelating to Coronavirus/COVID-19
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, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of large groups of people. CISVUSA and CISV Jacksonville Chapter (“CISV”) and Kims Open Door have put in place preventative measures to reduce the spread of COVID-19; however, CISV and Kims Open Door cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending CISV Chapter and CISV Junior Branch and Kims Open Door in-person activities could increase your risk and your child(ren)’s risk of contracting COVID-19.
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 infected by COVID-19 by attending a CISV and Kims Open Door in-person activity and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at a CISV and Kims Open Door in-person activity may result from the actions, omissions, or negligence of myself and others, including, but not limited to, CISV and Kims Open Door 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 my child(ren)’s attendance at in-person CISV and Kims Open Door activities (“Claims”). On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless CISV USA, CISV Jacksonville Chapter, Kims Open Door and their respective employees, volunteers, agents, and representatives, of and from the Claims, including 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 CISV USA, CISV Jacksonville Chapter, Kims Open Door or their employees, volunteers, agents, and representatives, whether a COVID-19 infection occurs before, during or after participation in any in-person CISV or Kims Open Door event or activity.
I agree
Signature
10. CISV does not want the program fees (if the program is not free) to be a consideration about whether your CISVer attends the program when you answer "yes" to any of the questions above . If your child misses all of the program due to possible COVID-19 exposure or any of the health conditions in this questionnaire, CISV will refund your fees. If you miss some days, CISV will refund a pro-rata portion of the fees. Please complete one of the options below about handling your refund.
Please let CISV keep by fees and consider it a donation.
Please give me my child's program T-shirt and refund me $20 of my child's participation fees.
Please refund any fees paid for days my child cannot attend.
Other
Email of Parent
example@example.com
Submit
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