REVO - High School League - Coronavirus Questionnaire - Required to be completed EVERY VISIT BY PLAYERS and SPECTATORS
This form must be completed by each parent, spectator, visitor, or skater prior to every practice, rental or visit to Revolution Ice Centre in order to enter the building. If you answer YES to any of these questions, please notify us immediately via email (info@revo-ice.com) and seek advice from your physician. If you answered "Yes" to any of these questions or do not agree with the contents, do not enter the rink. The information collected on this form will be used to determine only whether you may be infected with COVID-19 and pose a risk to other skaters, staff or coaches. The information on this form will be maintained as confidential.
Email address *
Your Name (person entering building) - PLEASE complete one for each player and one for each spectator. MUST BE 18 YEARS OLD OR OLDER TO COMPLETE. *
Team you are associated with *
Do you currently have any of the following: *
Yes
No
Cough, Fever, Headache, Diarrhea
Shortness of Breath, Chills / Shaking with Chills
Muscle Pain, Sore Throat, Loss of taste / smell
Have you or a member of your immediate family tested positive for COVID in the past 14 days? (NOTE- If you answer YES, please do not enter the building without pre-approval from our Management team. Please email info@revo-ice.com for action required.) *
If you answered "Yes" to any of these questions, do not enter the rink without pre-approval from our Management team. Please email info@revo-ice.com for action required. I hereby certify that the responses provided above are true and accurate to the best of my knowledge. *
The Participant and/or their parent(s) or guardian understands, acknowledges, and agrees that ice skating is an inherently dangerous and physically demanding activity. Participating skater assumes full responsibility for any risk of injury, property damage, or death while participating in activities at this establishment. Participant and/or their parent(s) or guardian hereby waive any and all claims including, but not limited to, bodily injury including death and property damage they may have against Revo Ice Centre, LLC, CLC Holding Group, LLC, Boston Road Properties, LLC and its subsidiaries, affiliates, owned or controlled companies, interest owners, co-lessees, contractors, and their officers, directors, partners, employees, volunteers and agents (hereinafter collectively referred to as “Revolution Ice Centre”) arising out of Participant's use of the ice skating rink and all surrounding areas. Participants and/or their parent(s) or guardians hereby release and hold harmless Revolution Ice Centre, including Revo Ice Centre, LLC, CLC Holding Group, LLC, Boston Road Properties, LLC and its subsidiaries, affiliates, owned or controlled companies, interest owners, co-lessees, contractors and their officers, partners, directors, employees, volunteers and agents from any and all liability for any loss, damage, or expense that the Participants or their respective heirs, assigns and legal representatives may suffer as a result of Participant's use of the ice skating rink, from any cause whatsoever, including but not limited to, negligence or breach of contract on the part of Revolution Ice Centre in the operation, supervision, design, maintenance, or condition of the ice surface, or of the ice rink and all surrounding areas. Participant agrees to abide by all rules and regulations, as posted within the ice rink area, for the use of the ice skating rink and will follow the instructions of the operating staff of the rink. Failure to follow these codes of conduct may result in the termination of Participant's use of the ice skating rink, the rental ice skates, and the surrounding areas without refund. Participant permits Revolution Ice Centre to use any photographs, videotapes, recordings or any other records taken while on the ice skating rink premises for publicity, advertising, or any other legitimate purpose. BY CLICKING "I AGREE", I UNDERSTAND THAT I AM RELEASING REVOLUTION ICE CENTRE FROM ANY POTENTIAL CLAIMS FOR NEGLIGENCE AND FOR ANY DAMAGES CAUSED BY REVOLUTION ICE CENTRE’S NEGLIGENCE. *
COVID RELEASE - The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. Revolution Ice Centre (“Revo”) has put in place preventative measures to reduce the spread of COVID-19; however, Revo cannot guarantee that you or your participants including child(ren) will not become infected with COVID-19. Further, attending Revo could increase your risk and your participants including child(ren)’s risk of contracting COVID-19. By clicking I AGREE, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending Revo and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Revo may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Revo employees, volunteers, and program participants and their families. *
I understand this data will be shared with rink administration as well as other people involved in the rental of ice at the facility. By clicking I AGREE, I authorize you to share this information. I also acknowledge that Revolution uses a thermal camera to check my players temperature upon entrance to the rink as well as facial recognition to record the readings. *
On November 17th, PA Department of Health’s Secretary Rachel Levine issued a new order related to COVID in the Commonwealth of PA. In accordance with OUT-OF-STATE TESTING rules announced by Pennsylvania's Secretary of Health, we will require that each non-PA resident complete a Self-Certification and Waiver that states that they are in compliance with this order. Due to HIPPA regulations, Revolution cannot collect any reports containing medical information such as diagnostic testing. Rather, in order to participate in any activity at Revolution, non-Pennsylvania residents must sign a Self-Certification and Waiver stating that they are in compliance with the Sec’y of Health’s November 17, 2020 Order. All other COVID mitigation rules will remain in effect until further notice. This OUT OF STATE SELF-CERTIFICATION should be completed within 24 hours of your arrival at Revolution Ice Centre. For more information on the Secretary of Health’s November 17, 2020 Order, please follow this link: https://www.health.pa.gov/topics/disease/coronavirus/Pages/Travelers.aspx *
SELF-CERTIFICATION *
A copy of your responses will be emailed to the address you provided.
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