COVID-19 Questionnaire and Waiver
Meeting participants must sign this agreement and complete the below screening process the morning of the Event (before arriving in person ).
COVID-19 QUESTIONNAIRE
Name of Meeting Participant
First Name
Last Name
Phone number of Meeting Participant
Please enter a valid phone number.
Format: (000) 000-0000.
Are you fully vaccinated against Covid-19?
Yes
No
1. Has the meeting participant been around someone who has tested positive for COVID-19 in the past 3 days?
Yes
No
2. Does the meeting participant have a temperature of 100.4F or higher taken by mouth?
Yes
No
3. Has the meeting participant had shortness of breath at rest or while being inactive?
Yes
No
4. Does the meeting 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 meeting participant have a sore throat, diarrhea, nausea, vomiting, muscle aches or a headache?
Yes
No
6. Does the meeting participant have chills or repeated shaking with chills?
Yes
No
7. Does the meeting participant have new loss or taste or smell?
Yes
No
If you answered yes to any of these questions, we ask that you do not attend the meeting in person but are welcome to join by video.
By clicking I agree, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending a CISV 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 in-person activity may result from the actions, omissions, or negligence of myself and others, including, but not limited to, CISV employees, volunteers and meeting participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and my family (including, but not limited to, personal injury, disability and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my family may experience or incur in connection with my attendance at in-person CISV activities (“Claims”). On my behalf, and on behalf of my family, I hereby release, covenant not to sue, discharge, and hold harmless CISV USA, CISV Jacksonville Chapter, the meeting hosts, 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, the meeting hostsor their employees, volunteers, agents, and representatives, whether a COVID-19 infection occurs before, during or after participation in any in-person CISV event or activity.
I agree
I agree to contact CISV Jacksonville Risk Manager Karen Lee Duffell at 904 571-0789 if I test positive for Covid-19 or show the symptoms listed in the questionnaire above during the program or within 3 days after any in-person activity.
Yes
Email of Meeting Participant
example@example.com
Submit
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