Document Text
--- Document: Return to Play Covid-19 Waiver Document ---
Township of
West Caldwell
Return to Play Waiver
PARTICIPANT INFORMATION
Name:
Team:
Date:
Have you been in close contact to a person who is lab-confirmed to have COVID-19 in the past 14 days?
_ Yes
No
If yes, what was the date of the last known contact?
COVID-19 DISCLOSURE, ACKNOWLEDGEMENT, & WAIVER
Are you exhibiting any of the following new or worsening symptoms of possible COVID-19?
Cough
Shortness of breath or difficulty breathing
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
Loss of taste or smell
Diarrhea
Feeling feverish or a measured temperature greater than or equal to 100.4 degrees Fahrenheit
Known close contact with a person who is lab confirmed to be COVID-19 positive
Currently living with someone experiencing symptoms of COVID-19
None of the above/no symptoms
Duty to inform
I will inform my coach or a League official if:
I knowingly come in contact with someone who tested positive within 14 days prior.
If I develop any of the above symptoms.
If I test positive for COVID-19.
COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is
believed to spread from person-to-person contact. Federal, state, and local governments and health agencies recommend social
distancing and have, in many areas, prohibited group activities.
The Township of West Caldwell is taking steps to reduce the spread of COVID-19; however, the Township cannot guarantee that you
or your child(ren) will not become infected with COVID-19. Further, attending Township of West Caldwell activities could increase
the risk of contracting COVID-19.
By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I
may be exposed to or get infected by COVID-19 by attending a Township of West Caldwell activity and that such exposure or infection
may result in personal injury, illness, permanent disability, and death. I understand the risk of becoming exposed to or infected by
COVID-19 may result from the act, omission, or negligence of myself and others, including, but not limited to, Township of West Caldwell
volunteers, and other participants and their families.
I voluntarily agree to assume the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but
not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren)
may incur by reason of a Township of West Caldwell activity (“Claims”). On my behalf, and on behalf of my child(ren), I hereby release
and covenant not to sue the Township of West Caldwell, its affiliated organizations, employees, volunteers, agents, and
representatives, of and from the Claims.
SIGNATURES
Participant Signature:
Parent Signature:
Witness Name:
Witness Signature: