EarlyON | Waterloo Region Parent and Legal Guardian Attestation-Mar 09, 2022

Region of Waterloo Public Health and Emergency Services requires us to screen all staff, visitors, and participants at all in-person EarlyON locations. If you or anyone with you today does not successfully pass the covid-19 screen, our staff are required to deny you entry into the building/the outdoor program.

This form will enable accurate screening of all adults and children attending in-person programming at an indoor or outdoor EarlyON location. Please note, that when a child is attending an EarlyON program (the “Services”) accompanied by an adult that is not their parent or legal guardian, this form must be completed by the parent or legal guardian and submitted electronically to the EarlyON and/or brought with the child to the EarlyON on entry at each visit. In the case where a parent/legal guardian is not accompanying their child to the centre, the parent must also complete the section for the non-participating adult to represent their responses. A new form must be completed for each visit to an EarlyON indoor or outdoor programming venue and must be completed on the day you plan to attend the program.

PLEASE READ THE TERMS IN SECTION B CAREFULLY, AS THEY AFFECT YOUR LEGAL RIGHTS. EarlyON Child and Family Centres in Waterloo Region are managed by the YMCA of Three Rivers as the Lead Agency, with the Region of Waterloo, Children's Services providing oversight and funding to the system.

Are you the parent or legal guardian of the child attending the EarlyON? *

Yes No

Visit Date (This form must be completed on the same day of the visit) *

Date

EarlyON Child and Family Centre your child will be attending today *

Parent/Legal Guardian 1 *

First Name Last Name

Phone Number *

Area Code Phone Number

Parent/Legal Guardian's Temperature on Day of Visit - Please record as actual temperature in degrees Celsius *

Child 1 *

First Name Last Name

Child 2

First Name Last Name

Child 3

First Name Last Name

The adult listed below will be bringing my child to the EarlyON location on today's date: *

First Name Last Name

Phone Number of Adult Attending the EarlyON *

Area Code Phone Number

A) Screening

As the parent or legal guardian of a child pre-registered to attend an EarlyON location with an adult who is not their parent or legal guardian, please answer the following questions for both your child(ren) and your household. If you inform us that you have any COVID-19 symptoms, an alternate diagnosis from a medical health professional must be verbally provided, and/or verbal confirmation of current vaccination status (within the last 48 hours) for those symptom questions that could be related to vaccinations is required. Without an alternate medical diagnosis, we will not be allowed to allow you to participate today. All questions require a yes or no response.

Please answer the COVID-19 Screening Questions for yourself as the Parent/Legal Guardian of a child attending an EarlyON location without you.

1. In the last [5, 10] days have you experienced any of these symptoms?
• If you are fully vaccinated, use 5 days
• If you are not fully vaccinated OR if you are immune compromised, use 10 days.
Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea) and should seek assessment from their health care provider if needed.
If you have completed your isolation of [5/10] days OR you tested negative for COVID-19 on a single PCR test or rapid molecular test, or two rapid antigen tests (RATs) taken 24-48 hours apart, AND you do not have a fever, AND your symptoms have been improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea), you may answer “no” to all symptoms.
Choose any/all that are new, worsening, and not related to other known causes or conditions
you already have.

a. Fever and/or chills? (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills). *

Yes No

b. Cough or barking cough (croup)? Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions you already have). *

Yes No

c. Shortness of breath? Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have). *

Yes No

d. Decrease or loss of taste or smell? Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have. *

Yes No

2. In the last [5, 10] days have you experienced any of these symptoms? *
• If you are fully vaccinated, use 5 days
• If you are not fully vaccinated OR if you are immune compromised, use 10 days.
If you only had one of these symptoms, you may select “No” if your symptom has been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea).
If you had two or more of these symptoms, you may select “No” if all of these apply:
• You have completed your isolation of [5/10] days OR you tested negative for COVID-19 on one PCR test or rapid molecular test, or two rapid antigen tests taken 24 to 48 hours apart AND
• You do not have a fever AND
• Your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting,
and/or diarrhea).

a. Sore throat or difficulty swallowing. Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have) *

Yes No

b. Runny or stuffy/congested nose. Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have *

Yes No

c. Headache. Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have). If you received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing a mild headache that only began after vaccination, select “No.” *

Yes No

d. Extreme tiredness. Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions you already have). If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.” *

Yes No

e. Muscle aches or joint pain. If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.” *

Yes No

f. Nausea, vomiting and/or diarrhea. Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have *

Yes No

3. In the last [5, 10] days have you tested positive for COVID-19?

This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test or home-based self-testing kit.

• If you are fully vaccinated, use 5 days
• If you are not fully vaccinated OR if you are immunocompromised, use 10 days.
Select “No” if you have already completed your isolation period of [5, 10] days because your symptoms started before your positive test result AND:
• your symptoms have been improving for 24 hours (48 for nausea, vomiting, and/or diarrhea) AND
• you do not have a fever

Your answer is: *

Yes No

4. Do any of the following apply?
• You live with someone who is currently isolating because of a positive COVID-19 test
• You live with someone who is currently isolating because of COVID-19 symptoms (any one or more symptoms from question 1 above or any two or more symptoms from question 2 above)
• You live with someone who is waiting for COVID-19 test results

Select “No” if you:

• are 18 years of age or older and have received your booster OR

• are 17 years of age or younger and are fully vaccinated OR

• completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test).

Select “No” if your household member is isolating because of COVID-19 symptoms
but has already tested negative on one PCR or rapid molecular test,
or two rapid antigen tests

Your answer is: *

Yes No

5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *

Yes No

6. Do any of the following apply?
• In the last 14 days, have you travelled outside of Canada and were told to quarantine
• In the last 14 days, have you travelled outside of Canada and were told to not attend school/child care

Your answer is: *

Yes No

Child 1 *

Name *

First Name Last Name

Child # 1 Temperature on Day of Visit - Please record as actual temperature in degrees Celsius *

1. In the last [5, 10] days has your child experienced any of these symptoms? *
• If your child is fully vaccinated OR 11 years old or younger, use 5 days.
• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days.
Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea) and should seek assessment from their health care provider if needed.
If your child has completed their isolation of [5/10] days OR they tested negative for COVID-19 on a single PCR test or rapid molecular test, or two rapid antigen tests (RATs) taken 24-48 hours apart, your child does not have a fever, and symptoms have been improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea), you may answer “no” to all symptoms.
Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

a. Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills)? *

Yes No

b. Cough or barking cough (croup)? Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have). *

Yes No

c. Shortness of breath? Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have). *

Yes No

d. Decrease or loss of taste or smell? Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have. *

Yes No

2. In the last [5, 10] days has your child experienced any of these symptoms? *
• If your child is fully vaccinated OR 11 years old or younger, use 5 days
• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days

If your child only had one of these symptoms, you may select “No” if their symptom has been improving for 24 hours (48 hours if your child has nausea, vomiting, and/or diarrhea).
If your child had two or more of these symptoms, you may select “No” if all of these apply:
• Your child has completed their isolation of [5/10] days OR they tested negative for COVID-19 on one PCR test or rapid molecular test, or two rapid antigen tests taken 24 to 48 hours apart AND
• Your child does not have a fever AND
• Their symptoms have been improving for 24 hours (48 hours if your child has nausea, vomiting,
and/or diarrhea).

Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

a. Sore throat or difficulty swallowing. Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have) *

Yes No

b. Runny or stuffy/congested nose. Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have *

Yes No

c. Headache. Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have). If your child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing a mild headache that only began after vaccination, select “No.” *

Yes No

d. Extreme tiredness. Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions they already have). If your child received a COVID-19 and/or flu vaccination in the last 48 hour sand is experiencing mild fatigue that only began after vaccination, select “No.” *

Yes No

e. Muscle aches or joint pain. If your child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing mild muscle aches/joint pain that only began after vaccination, select “No.” *

Yes No

f. Nausea, vomiting and/or diarrhea. Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have *

Yes No

3. In the last [5, 10] days has your child tested positive for COVID-19?

This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test or home-based self-testing kit.

• If your child is fully vaccinated OR 11 years old or younger, use 5 days;

• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days.

Select “No” if your child has already completed their isolation period of [5, 10] days because their symptoms started before their positive test result AND:

• their symptoms have been improving for 24 hours (48 for nausea, vomiting,and/or diarrhea) AND

• your child does not have a fever

Your answer is: *

Yes No

4. Do any of the following apply?
• Your child lives with someone who is currently isolating because of a positive COVID-19 test

• Your child lives with someone who is currently isolating because of COVID-19 symptoms (any one or more symptoms from question 1 above or any two or more symptoms from question 2 above)

• Your child lives with someone who is waiting for COVID-19 test results

Select “No” if your child:

• is 17 years of age or younger and are fully vaccinated OR

• completed their isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test).

Select “No” if your household member is isolating because of COVID-19 symptoms
but has already tested negative on one PCR or rapid molecular test,
or two rapid antigen tests.

Your answer is: *

Yes No

5. Has a doctor, health care provider, or public health unit told you that your child should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *

Yes No

6. Do any of the following apply?
• In the last 14 days, your child travelled outside of Canada and was told to quarantine
• In the last 14 days, your child travelled outside of Canada and was told to not attend school/child care

Your answer is: *

Yes No

Child 2

Name

First Name Last Name

Child # 2 Temperature on Day of Visit - Please record as actual temperature in degrees Celsius

1. In the last [5, 10] days has your child experienced any of these symptoms?
• If your child is fully vaccinated OR 11 years old or younger, use 5 days.
• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days.
Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea) and should seek assessment from their health care provider if needed.
If your child has completed their isolation of [5/10] days OR your child tested negative for COVID-19 on a single PCR test or rapid molecular test, or two rapid antigen tests (RATs) taken 24-48 hours apart, AND your child does not have a fever, AND symptoms have been improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea), you may answer “no” to all symptoms.
Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

a. Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills)?

Yes No

b. Cough or barking cough (croup)? Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have).

Yes No

c. Shortness of breath? Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have).

Yes No

d. Decrease or loss of taste or smell? Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have.

Yes No

2. In the last [5, 10] days has your child experienced any of these symptoms?
• If your child is fully vaccinated OR 11 years old or younger, use 5 days
• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days

If your child only had one of these symptoms, you may select “No” if their symptom has been improving for 24 hours (48 hours if your child has nausea, vomiting, and/or diarrhea).
If your child had two or more of these symptoms, you may select “No” if all of these apply:
• Your child has completed their isolation of [5/10] days OR your child tested negative for COVID-19 on one PCR test or rapid molecular test, or two rapid antigen tests taken 24 to 48 hours apart AND
• Your child does not have a fever AND
• Their symptoms have been improving for 24 hours (48 hours if your child has nausea, vomiting,
and/or diarrhea).
Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

a. Sore throat or difficulty swallowing. Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)

Yes No

b. Runny or stuffy/congested nose. Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Yes No

c. Headache. Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have). If your child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing a mild headache that only began after vaccination, select “No.”

Yes No

d. Extreme tiredness. Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions they already have). If your child received a COVID-19 and/or flu vaccination in the last 48 hour sand is experiencing mild fatigue that only began after vaccination, select “No.”

Yes No

e. Muscle aches or joint pain. If your child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”

Yes No

f. Nausea, vomiting and/or diarrhea. Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have

Yes No

3. In the last [5, 10] days has your child tested positive for COVID-19?

This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test or home-based self-testing kit.

• If your child is fully vaccinated OR 11 years old or younger, use 5 days;

• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days.

Select “No” if your child has already completed their isolation period of [5, 10] days because their symptoms started before their positive test result AND:

• their symptoms have been improving for 24 hours (48 for nausea, vomiting,and/or diarrhea) AND

• your child does not have a fever

Your answer is:

Yes No

4. Do any of the following apply?
• Your child lives with someone who is currently isolating because of a positive COVID-19 test

• Your child lives with someone who is currently isolating because of COVID-19 symptoms (any one or more symptoms from question 1 above or any two or more symptoms from question 2 above)

• Your child lives with someone who is waiting for COVID-19 test results

Select “No” if your child:

• is 17 years of age or younger and are fully vaccinated OR

• completed their isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test).

Select “No” if your household member is isolating because of COVID-19 symptoms
but has already tested negative on one PCR or rapid molecular test,
or two rapid antigen tests.

Your answer is:

Yes No

5. Has a doctor, health care provider, or public health unit told you that your child should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing.

Yes No

6. Do any of the following apply?
• In the last 14 days, your child travelled outside of Canada and was told to quarantine
• In the last 14 days, your child travelled outside of Canada and was told to not attend school/child care

Your answer is:

Yes No

Child 3

Name

First Name Last Name

Child #3 Temperature on Day of Visit - Please record as actual temperature in degrees Celsius

1. In the last [5, 10] days has your child experienced any of these symptoms?
• If your child is fully vaccinated OR 11 years old or younger, use 5 days
• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days
Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea) and should seek assessment from their health care provider if needed.
If your child has completed their isolation of [5/10] days OR your child tested negative for COVID-19 on a single PCR test or rapid molecular test, or two rapid antigen tests (RATs) taken 24-48 hours apart, AND your child does not have a fever, AND symptoms have been improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea), you may answer “no” to all symptoms.
Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

a. Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills)?

Yes No

b. Cough or barking cough (croup)? Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have).

Yes No

c. Shortness of breath? Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have).

Yes No

d. Decrease or loss of taste or smell? Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have.

Yes No

2. In the last [5, 10] days has your child experienced any of these symptoms?
• If your child is fully vaccinated OR 11 years old or younger, use 5 days
• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days

If your child only had one of these symptoms, you may select “No” if their symptom has been improving for 24 hours (48 hours if your child has nausea, vomiting, and/or diarrhea).
If your child had two or more of these symptoms, you may select “No” if all of these apply:
• Your child has completed their isolation of [5/10] days OR they tested negative for COVID-19 on one PCR test or rapid molecular test, or two rapid antigen tests taken 24 to 48 hours apart AND
• Your child does not have a fever AND
• Their symptoms have been improving for 24 hours (48 hours if your child has nausea, vomiting,
and/or diarrhea).
Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

a. Sore throat or difficulty swallowing. Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)

Yes No

b. Runny or stuffy/congested nose. Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Yes No

c. Headache. Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have). If your child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing a mild headache that only began after vaccination, select “No.”

Yes No

d. Extreme tiredness. Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions they already have). If your child received a COVID-19 and/or flu vaccination in the last 48 hour sand is experiencing mild fatigue that only began after vaccination, select “No.”

Yes No

e. Muscle aches or joint pain. If your child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”

Yes No

f. Nausea, vomiting and/or diarrhea. Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have

Yes No

3. In the last [5, 10] days has your child tested positive for COVID-19?

This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test or home-based self-testing kit.

• If your child is fully vaccinated OR 11 years old or younger, use 5 days;

• If your child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days.

Select “No” if your child has already completed their isolation period of [5, 10] days because their symptoms started before their positive test result AND:

• their symptoms have been improving for 24 hours (48 for nausea, vomiting,and/or diarrhea) AND

• your child does not have a fever

Your answer is:

Yes No

4. Do any of the following apply?
• Your child lives with someone who is currently isolating because of a positive COVID-19 test

• Your child lives with someone who is currently isolating because of COVID-19 symptoms (any one or more symptoms from question 1 above or any two or more symptoms from question 2 above)

• Your child lives with someone who is waiting for COVID-19 test results

Select “No” if your child:

• is 17 years of age or younger and are fully vaccinated OR

• completed their isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test).

Select “No” if your household member is isolating because of COVID-19 symptoms
but has already tested negative on one PCR or rapid molecular test,
or two rapid antigen tests.

Your answer is:

Yes No

5. Has a doctor, health care provider, or public health unit told you that your child should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing.

Yes No

6. Do any of the following apply?
• In the last 14 days, your child travelled outside of Canada and was told to quarantine
• In the last 14 days, your child travelled outside of Canada and was told to not attend school/child care

Your answer is:

Yes No

B) Consent and Release

I agree that by signing below (whether electronically or in hard form), I create a binding legal agreement (the “Agreement”) made by you and any minor (being a person under the age of 18 years) and any other person for whom you are responsible, including without limitation your children or other members of your family, (collectively referred to as “You” or “Your”) in favour of the The Regional Municipality of Waterloo (the Region”), and any EarlyON Service Provider within Waterloo Region governing Your use of the Services during the Novel Coronavirus (“COVID-19”) pandemic.

COVID-19 Release

EarlyON Child and Family Centres are following the guidance provided by the Province of Ontario through the Ministry of Education and local Public Health to protect the health of all participants during the COVID-19 pandemic. However, despite these enhanced safety measures, there is still the possibility that you may get COVID-19. By signing this form You forever release the Region from any and all liability for any and all claims, demands, actions, damages (including direct, indirect, special and/or consequential), losses, actions, judgments, and costs (including legal fees) (collectively, the “Claims”) which You may have or may in the future have, that might arise out of, result from, or relate to You being exposed to COVID-19 or You exposing any member, other guest or the Centre to COVID-19 as a result of Your use of the services even though such Claims may have been caused by any manner whatsoever, including but not limited to, the negligence, gross negligence, negligent rescue, omissions, carelessness, breach of contract and/or breach of any statutory duty of care of the Region and/or EarlyON Service Provider.

You agree to indemnify and hold harmless the Region and any EarlyON Service Provider against any and all Claims brought by You or anyone on Your behalf if litigation arises pursuant to any Claims made by You or anyone else acting on Your behalf. Likewise, You agree to indemnity and hold harmless the Region of Waterloo and any EarlyON Service Provier against any and all Claims, brought by a third party as a result of Your attendance, actions, or inactions at any of the EarlyON Child and Family Centre premises. If the Region of Waterloo or any EarlyON Service Provider incurs any expenses in relation to any of these types of Claims, You agree to immediately reimburse the Region of Waterloo and/or the EarlyON Service Provider.

In consideration of my child(ren) participating in the Services, By signing below (whether electronically or in hard form), I hereby provide my consent for my child(ren) to participate in in-person programming at the EarlyON Child and Family Centre and agree to the above terms and conditions.

Name *

First Name Last Name

Date *

Date

Signature *

Note: where children are listed on the form, the signature MUST be of their parenting or legal guardian. Clear

Notice of Collection: The information collected on this form is at the direction of the Province of Ontario, through the Ministry of Education (Rules for child care and early years programs) and the Region of Waterloo Public Health (Waterloo Region Child care centres and early years’ settings guidance). The purpose of the collection is to help ensure the health and safety of the participants and staff attending EarlyON Child and Family Centre programs in Waterloo Region, and to support contact tracing by Region of Waterloo Public Health during the COVID-19 pandemic, should that be necessary.

Should you have any questions about the collection of information please contact the Region of Waterloo, Manager, Early Learning Services at 519-575-4400, ext. 5429 or at ksanguesa@regionofwaterloo.ca, or the Director of EarlyON Operations at 519-741-8585 ext. 3112, or at stacey.mccormick@ytr.ymca.ca.

EarlyON | Waterloo Region Parent or Legal Guardian Attestation Screening Form and Release