COVID Waiver | Canmore Seniors Association

Please complete the following Alberta Health Checklist and sign the assumption of risk and waiver of liability relating to COVID 19 prior to participating in activity with the Canmore Seniors Association. This form must be completed and signed each time you participate in an activity.

Date *

Name *

First

Last

CSA member number *

You must be a member to participant in CSA activities.

Phone number *

Required for COVID contract tracing.

Email *

Confirm Email

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.

Do you have any new onset (or worsening) of any of the following symptoms? *

Yes
No symptoms

• 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)

Have you travelled outside of Canada in the last 14 days? *

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? *

Have you had close unprotected contact (within 6 feet) in the last 14 days with someone who is ill with COVID 19 symptoms? *

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? *

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.