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 *

    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


    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.

    Participant's Signature*

    Minors Name



    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*





    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    Phone*

    First 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?*

    Second Minor's Name



    Phone*

    Second 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



    Phone*

    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    Phone*

    First 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? *

    Second Minor's Name



    Phone*

    Second 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? *

    Third Minors Name



    Phone*

    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? *

    Parent or Guardian's Name



    Phone*

    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    Phone*

    First 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? *

    Second Minor's Name



    Phone*

    Second 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? *

    Third Minors Name



    Phone*

    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



    Phone*

    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? *

    Parent or Guardian's Name



    Phone*

    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    Phone*

    First 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? *

    Second Minor's Name



    Phone*

    Second 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? *

    Third Minors Name



    Phone*

    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



    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



    Phone*

    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? *

    Parent or Guardian's Name



    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    Phone*

    First 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? *

    Second Minor's Name



    Second 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? *

    Third Minors Name



    Phone*

    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



    Phone*

    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



    Phone*

    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



    Phone*

    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? *

    Parent or Guardian's Name



    Phone*

    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    Phone*

    First 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? *

    Second Minor's Name



    Phone*

    Second 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? *

    Third Minors Name



    Phone*

    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



    Phone*

    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



    Phone*

    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



    Phone*

    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



    Phone*

    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? *

    Parent or Guardian's Name



    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    First 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? *

    Second Minor's Name



    Second 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? *

    Third Minors 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



    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



    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



    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



    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



    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? *

    Parent or Guardian's Name



    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    First 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? *

    Second Minor's Name



    Second 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? *

    Third Minors 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



    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



    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



    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



    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



    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



    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? *

    Parent or Guardian's Name



    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.

    Parent or Guardian's Signatures*

    First Minor's Name



    First 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? *

    Second Minor's Name



    Second 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? *

    Third Minors 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



    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



    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



    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



    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



    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



    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



    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



    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.

    Parent or Guardian's Signatures*