USC-COVID-19 Self-Declaration Form – Just another WordPress site

United Soccer Centre

3413 Wolfedale Rd, Unit 15, Mississauga | 905 -361-0530 | infomiss@unitedsoccercentre.com

United Soccer Centre Mississauga is excited to be open and offering training facilities.
To ensure that everyone stays safe and healthy we ask that you complete this form prior to entering the facility.
If you have not completed this form you will not be able to enter.

Location:*

Fields/Rooms *

Participant's Name*

Phone*

Participant's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?**

5. Have you tested positive for COVID-19 within the last 10 days?*

Waiver Consent

1. COVID-19 can be transmitted by asymptomatic people and the statements made by members contained in this document cannot provide certainty that COVID-19 will not be transmitted. USC Mississauga Inc is taking steps to impose and enforce appropriate protocols to keep you and other members safe, but there can be no assurance that COVID-19 will not be contracted. This is a risk that each member must assess themselves, and if you choose to come to USC Mississauga Inc, you assume the risk of either contracting COVID-19 or transmitting it to others. 2. USC Mississauga Inc is not responsible for any illness, injury, property damage, expense, loss of income, damage, or loss of any kind suffered by you, including should you contract COVID-19 during, or as a result of, your use of USC Mississauga Inc, caused in any manner whatsoever including but not limited to, the negligence of USC Mississauga Inc, its owners, employees, directors and members. 3. You hereby declare that prior to any visit to USC Mississauga Inc, neither you, or anyone else in your household has experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing). If you or anyone in your household experience any cold or flu-like symptoms after submitting this form, you will not visit USC Mississauga Inc for a minimum period of 14 days after the cold or flu-like symptoms have completely gone away. 4. You hereby declare that you or any member of your household have not been to, travelled to, visited or had a lay-over in any country outside Canada in the past 14 days. If you or anyone in your household travels to any country outside Canada after submitting this form, you will not visit USC Mississauga Inc for a minimum period of 14 days after the date of return to Canada. 5. You acknowledge that you have read this Agreement and understand it. You have had the opportunity to review this Agreement and you acknowledge that you have executed this Agreement voluntarily and agree to be bound by this Agreement. You further acknowledge that this Agreement is binding upon yourself, your heirs, spouse, children, parents, guardians, executors, administrators and legal or personal representatives.

Minors Name

First Name*

Last Name*

Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?**

5. Have you tested positive for COVID-19 within the last 10 days?*

Parent or Guardian's Name*

First Name*

Last Name*

Phone*

Enter 3 Letter Initials*

Waiver Consent

First Minor's Name

First Name*

Last Name*

Phone*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?**

5. Have you tested positive for COVID-19 within the last 10 days?*

Second Minor's Name

First Name*

Last Name*

Phone*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Phone*

Waiver Consent

First Minor's Name

First Name*

Last Name*

Phone*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Phone*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Phone*

Third Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Phone*

Waiver Consent

First Minor's Name

First Name*

Last Name*

Phone*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Phone*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Phone*

Third Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fourth Minors Name

First Name*

Last Name*

Phone*

Fourth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Phone*

Waiver Consent

First Minor's Name

First Name*

Last Name*

Phone*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Phone*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Phone*

Third Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fourth Minors Name

First Name*

Last Name*

Fourth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fifth Minors Name

First Name*

Last Name*

Phone*

Fifth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Waiver Consent

First Minor's Name

First Name*

Last Name*

Phone*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Phone*

Third Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fourth Minors Name

First Name*

Last Name*

Phone*

Fourth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fifth Minors Name

First Name*

Last Name*

Phone*

Fifth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Sixth Minors Name

First Name*

Last Name*

Phone*

Sixth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Phone*

Waiver Consent

First Minor's Name

First Name*

Last Name*

Phone*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Phone*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Phone*

Third Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fourth Minors Name

First Name*

Last Name*

Phone*

Fourth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fifth Minors Name

First Name*

Last Name*

Phone*

Fifth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Sixth Minors Name

First Name*

Last Name*

Phone*

Sixth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Seventh Minors Name

First Name*

Last Name*

Phone*

Seventh Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Waiver Consent

First Minor's Name

First Name*

Last Name*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Third Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fourth Minors Name

First Name*

Last Name*

Fourth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fifth Minors Name

First Name*

Last Name*

Fifth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Sixth Minors Name

First Name*

Last Name*

Sixth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Seventh Minors Name

First Name*

Last Name*

Seventh Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Eighth Minors Name

First Name*

Last Name*

Eighth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Waiver Consent

First Minor's Name

First Name*

Last Name*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Third Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fourth Minors Name

First Name*

Last Name*

Fourth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fifth Minors Name

First Name*

Last Name*

Fifth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Sixth Minors Name

First Name*

Last Name*

Sixth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Seventh Minors Name

First Name*

Last Name*

Seventh Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Eighth Minors Name

First Name*

Last Name*

Eighth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Ninth Minors Name

First Name*

Last Name*

Ninth Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

Waiver Consent

First Minor's Name

First Name*

Last Name*

First Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Second Minor's Name

First Name*

Last Name*

Second Minor's Information

Rental Date(dd/mm/yyyy)*

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Third Minors Name

First Name*

Last Name*

Third Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fourth Minors Name

First Name*

Last Name*

Fourth Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Fifth Minors Name

First Name*

Last Name*

Fifth Minor's Date of Birth*

Fifth Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Sixth Minors Name

First Name*

Last Name*

Sixth Minor's Date of Birth*

Sixth Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Seventh Minors Name

First Name*

Last Name*

Seventh Minor's Date of Birth*

Seventh Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Eighth Minors Name

First Name*

Last Name*

Eighth Minor's Date of Birth*

Eighth Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Ninth Minors Name

First Name*

Last Name*

Ninth Minor's Date of Birth*

Ninth Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Tenth Minors Name

First Name*

Last Name*

Tenth Minor's Date of Birth*

Tenth Minor's Information

1. Do you have any of the symptoms below:

Fever (greater than 38.0 C)*

Cough*

Shortness of Breath*

Sore Throat*

Runny Nose*

2. Have you or anyone in your household travelled outside of Canada in the last 14 days?*

3. Have you, or anyone in your household been in contact in the last 14 days with someone who is being confirmed to be a case of COVID-19?*

4. Are you currently being investigated as a suspected case of COVID-19?*

5. Have you tested positive for COVID-19 within the last 10 days? *

Parent or Guardian's Name

First Name*

Last Name*

United Soccer Centre

Please select who will be participating... *

This agreement is just for YOU

This agreement is for 1 minor

This agreement is for 2 minor

This agreement is for 3 minor

This agreement is for 4 minor

This agreement is for 5 minor

This agreement is for 6 minor

This agreement is for 7 minor

This agreement is for 8 minor

This agreement is for 9 minor

This agreement is for 10 minor

Participant's Name*

Phone*

Participant's Information

Waiver Consent

Participant's Signature*

Minors Name

Minor's Information

Parent or Guardian's Name*

Waiver Consent

Parent or Guardian's Signatures*

First Minor's Name

Phone*

First Minor's Information

Second Minor's Name

Phone*

Second Minor's Information

Parent or Guardian's Name

Phone*

Waiver Consent

Parent or Guardian's Signatures*

First Minor's Name

Phone*

First Minor's Information

Second Minor's Name

Phone*

Second Minor's Information

Third Minors Name

Phone*

Third Minor's Information

Parent or Guardian's Name

Phone*

Waiver Consent

Parent or Guardian's Signatures*

First Minor's Name

Phone*

First Minor's Information

Second Minor's Name

Phone*

Second Minor's Information

Third Minors Name

Phone*

Third Minor's Information

Fourth Minors Name

Phone*

Fourth Minor's Information

Parent or Guardian's Name

Phone*

Waiver Consent

Parent or Guardian's Signatures*

First Minor's Name

Phone*

First Minor's Information

Second Minor's Name

Phone*

Second Minor's Information

Third Minors Name

Phone*

Third Minor's Information

Fourth Minors Name

Fourth Minor's Information

Fifth Minors Name

Phone*

Fifth Minor's Information

Parent or Guardian's Name

Waiver Consent

Parent or Guardian's Signatures*

First Minor's Name