Program Participant Illness Questionnaire

 

[Please separate with a comma. Ex: 1,2,3...]

SYMPTOMS IN THE LAST 7 DAYS - Check any that apply

Fever (above 100.4º F)
Cough
Shortness of breath
Body aches
Change in taste or smell
Change in appetite
Generally not feeling well

PRE-EXISTING ILLNESSES - Check any that apply

Cardiovascular Disease        Respiratory Disease including Asthma
Diabetes                                Immunocompromised
If any of the above apply, please call (706)543-6596 or email office@athensymca.org prior to arrival.

CONTACT HISTORY - Check any that apply to your camper

The individual has been diagnosed with COVID-19.
The individual has a close contact that has been in contact with some one exposed to or infected with COVID-19 in the last 14 days.
The individual has a household member currently on the watch list for COVID-19 Exposure.
If any of the above apply, please call (706)543-6596 or email office@athensymca.org prior to arrival.

ACKNOWLEDGEMENT OF RISK

In my legal capacity as the parent/guardian of the minor named above, I do hereby acknowledge, and agree that participation in youth program activities comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with youth program participation, including but in no way limited to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to and infection with viruses or bacteria.

Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death.

Participating in Athens YMCA programs could increase the risk of contracting COVID-19. The Athens YMCA in no way warrants that COVID-19 infection will not occur through participation in youth program activities or accessing Athens YMCA facilities.

 

WAIVER, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE

I,  , the parent / guardian of the minor named above, do hereby

acknowledge, and agree to release and on behalf of myself and the minor named above, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE the Athens YMCA, its officers, directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, the named minor, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against the Athens YMCA on account of personal injury, property damage, illness, death or accident of any kind, arising out of or in any way related to the use of the facilities/equipment, participation in Athens YMCA programs or medical decisions by Releasees whether that participation is supervised or unsupervised, however the injury, illness, or damage occurs, including, but not limited to the negligence of Releasees.

In consideration of the named minor’s participation in youth program activities, I, the undersigned parent/guardian of the named minor, agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to the named minor’s youth program participation.

I hereby certify on behalf of myself and the named minor that I have full knowledge of the nature and extent of the risks inherent in youth program participation and that I, on behalf of myself and the named minor, am voluntarily assuming said risks even those caused solely or partially by the negligence or Releasees I understand that I and the named minor will be solely responsible for any loss or damage, including personal injury, property damage, illness, or death, the named minor sustains while participating in youth programs and that by signing this agreement I, on behalf of myself and the named minor, HEREBY RELEASE Releasees of all liability for such loss, damage, illness, or death.

I further understand that the terms of this agreement are legally binding and certify that I am signing this agreement, after having carefully read it, of my own free will.

This situation continues to change daily, and as such, we will adapt and adjust our protocols and our procedures as we follow the guidelines provided by the State of Georgia, CDC, and local health department, in our efforts to help keep our participants, staff and families safe.

 

 
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