COVID-19 Checklist & Waiver Form 2022

Today's Volunteer Date: *

Name *

First Name Last Name

Phone Number *

Email

example@example.com

Have you, or any children brought with you today, had a fever (100.4 degrees or higher) in the past 24 hours? *

Yes No

Have you (or any children brought with you today) experienced any of the following symptoms in the past 48 hours? Check all symptoms that are a "Yes." *

Have you tested positive or been diagnosed by a licensed health care provider with COVID in the past 10 days? *

Yes No

Are you, or anyone living in your home, currently waiting for results of a COVID test? *

Yes No

Have you, or anyone living in your home, been in close contact with someone diagnosed with COVID in the past 10 days? *

Yes No

I acknowledge the contagious nature of COVID-19, and I further acknowledge that Sidewalk Hope follows CDC protocols for the benefit of the communities we serve and the variety of needs among all volunteers.

I understand the following: Sidewalk Hope does not require volunteers to have a COVID vaccination or to be tested in order to serve as a volunteer. Wearing personal protection masks is optional unless recommended under CDC guidelines for specific circumstances, or if community levels of infection indicate higher safety measures are appropriate. Sidewalk Hope does provide masks for anyone who desires to wear one. I understand I am responsible to follow appropriate safety protocols while volunteering with Sidewalk Hope, and I further acknowledge I may still be at risk of contracting the virus even when using precautions.

With full knowledge of these risks, I hereby forever waive and discharge Sidewalk Hope, its board, officers, employees, representatives, and assigns from any and all liabilities, claims, demands, actions, and causes of action directly or indirectly arising out of or related to any loss, damage, injury, or death that may be sustained by me or my family related to COVID.

If I bring minor children (under the age of 18) to volunteer with Sidewalk Hope, I acknowledge and agree they are to be under my constant watch, care, and supervision while working as volunteers. I understand the above waiver also applies to any children under my care and brought to Sidewalk Hope activities.

I voluntarily agree to assume risks mentioned and accept sole responsibility for any injury or illness to myself or my child(ren) that may be experienced or incurred in connection with our voluntary attendance as a Sidewalk Hope volunteer.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE:

Signature *

IF YOU HAVE BROUGHT MINOR CHILDREN WITH YOU:

I am the parent or legal guardian of the minor children named below who are attending volunteer activities under my care and supervision today. I have the legal right to consent to and, by my signature above, I do hereby consent to the terms and conditions of this Waiver on their behalf.

Child's Name: First Name Last Name

Sidewalk Hope

Please answer each question: