HBSC COVID-19 Screening Questionnaire and Acknowledgement
It is important that you read, understand, complete this alert and questionnaire and acknowledgement.

With the continuing concerns arising from COVID-19, HBSC is taking the necessary precautions to prevent, or limit exposure to COVID-19 and to ensure appropriate health and safety measures are taken on HBCC property and during HBSC activities For all employees, visitors, members, and volunteers to HBSC property: PRIOR to entering the HBSC property this questionnaire and acknowledgement must be completed and returned.

Completion of this questionnaire is voluntary. However, if not completed, you WILL NOT be permitted entry to HBSC property.

All responses to this questionnaire shall be treated as confidential and shall only be disclosed to individuals as permitted by law.

We thank you for your cooperation in responding to the questions below.
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Name: *
Have you returned from travel outside of Canada within the last 14 days? *
Do you have at least two of the following symptoms? *
Fever above 38 degrees Celsius, New or worsening cough, Sore throat, Runny nose, Headache, New onset fatigue, New onset muscle pain, Diarrhea, Loss of taste, Loss of smell
Have you been in close contact (defined as in the same room or workplace for over 15 minutes) with a person who has a confirmed or suspected case of the COVID-19 infection? *
Acknowledgement and Waiver
By signing this Questionnaire, or by completing and submitting this Questionnaire electronically, I agree to the following:
1
If I experience any symptoms of Fever (or signs of a fever such as chills, sweats, muscle-aches and light-headedness), cough, headache, sore throat, runny nose, or have been in contact with anyone who have been suspected or confirmed to have COVID-19, or have been in contact with anyone who has symptoms of Fever (or signs of a fever such as chills, sweats, muscle aches and light-headedness),cough, headache, sore throat, runny nose after signing or submitting this Questionnaire, I will advise my instructor or an HBSC Board Member immediately and I will not enter HBSC property until cleared to do so;
I agree to Section 1 *
Required
2
I will report any symptoms of Fever (or signs of a fever such as chills, sweats, muscle aches and light-headedness), cough, headache, sore throat, runny nose, while at HBSC property to my instructor or an HBSC Board Member immediately and follow their directions respecting access to HBSC property and contact with public health or otherwise accessing medical care, as the case may be;
I agree to Section 2 *
Required
3
I have read and will comply with the HBSC Safety Protocols for Covid-19 including maintaining physical distancing at all times while on HSBC property, and will follow the instructions of HBSC personnel in respect of Covid-19 safety.
I agree to Section 3 *
Required
4
By attending Humber Bay Sailing Centre property (the “Club”), you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that your guests, family and you may be exposed to or infected by COVID-19 by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, and death. You understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of yourself and others, including, but not limited to, Club employees, club members, agents, representatives and other guests and their families.

You voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to your guests, family or yourself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that your guests, family and you may experience or incur in connection with your attendance at the Club.

On your behalf, and on behalf of your family from the same household, by attending at the Club, you hereby release, covenant not to sue, discharge, and hold harmless the Club, its employees, members, board members, agents, and representatives, of and from any Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. You understand and agree that this includes any Claims based on the actions, omissions, or negligence of the Club, its employees, members, board members, agents, and representatives, whether a COVID-19 infection occurs before, during, or after attendance at the Club.
I agree to Section 4 *
Required
If any of the following apply to you:
- 65 years old or older
- pregnant or recently gave birth
- getting treatment that compromises (weakens) your immune system(for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)
- having a condition that compromises (weakens) your immune system(for example, lupus, rheumatoid arthritis, other autoimmune disorder)
- having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition)
- regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

You are strongly recommended to consult your physician or public health resources to help you decide if you should attend at HBSC property.
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