Have you or anyone in your household traveled outside of Canada in the last 14 days? *
Do you have a fever? *
Do you have any symptoms of COVID-19 such as sore throat, stomach pains, cough? *
Studio XIV Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19
This waiver form must be signed and returned to dance studio with an acknowledgement before any use of the facilities is made. Individuals who have traveled outside of Canada within the previous 14 days or who are sick or who have been in contact with someone who is suspected of having COVID-19 must not use the facilities or attend dance classes. This access may be withdrawn at anytime based on health agency recommendations
I would like to participate in dance/education classes at Studio XIV Dance Company. In response to efforts to contain the spread of COVID-19 corona virus, I am aware that I am using the facilities at my own risk and will ensure that I will conduct myself in a way that is appropriate. I confirm that I have not traveled outside of Canada for the past 14 days and have not been in contact with anyone who is suspected of having COVID-19. I do not have any symptoms of COVID-19 including but not limited to fever, sore throat, coughing, aches, respiratory problems, dry cough, fatigue, diarrhea, loss of taste or smell, chest pain, rash on skin, discoloration of fingers or toes, headache. The novel corona virus, 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. Studio XIV Dance Company has put in place preventative measures to reduce the spread of COVID-19; however, Studio XIV Dance Company cannot guarantee that you will not become infected with COVID-19. Attending any public spaces increases your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, 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 Studio XIV Dance Company 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 Studio XIV Dance Company may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Studio XIV Dance Company Ltd employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Studio XIV Dance Company or participation in programs at Studio XIV Dance Company. On my behalf, I hereby release ,covenant not to sue, discharge, and hold harmless the Dance Studio, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the Studio XIV Dance Company, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Studio XIV Dance Company program.
I have read, understand, and agree to the above terms of participation and the assumption of risk of participation and release all liability. ENTER NAME BELOW: *
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