Team Jeromy COVID-19 Readiness
Please complete this form prior to each meeting or other campaign activities. This assists us in screening all volunteers to ensure that everyone is safe to attend our events and our community remains healthy. Thank you for your help with this!
Email address *
Name (First, Last) *
Activity Date *
MM
/
DD
/
YYYY
Campaign Events/Places
Please choose where you are involved. For multiple areas please enter your time of presence in ALL corresponding areas below.
Yes, I am here
Campaign office
Door Knocking
Delivery of Signs
Events
Traveling
Other
If You Chose "Other" Please Specify
Start time of activities
Time
:
Please complete the AHS COVID-19 Self Assessment, found here: https://myhealth.alberta.ca/journey/covid-19/Pages/COVID-Self-Assessment.aspx. By clicking the box below, you acknowledge that you have completed the AHS Self-Assessment and that you have no symptoms or previous exposure that would prohibit you from attending campaign activities. *
Required
*CONSENT TO RISK & WAIVER OF LEGAL RIGHTS* Although your health and safety is our top priority, Farkas for Calgary Campaign cannot and does not provide any assurance that you will not contract COVID-19 while participating in its activities. By clicking the box below, you are acknowledging and consenting to the risk of exposure to COVID-19 by participating in activities with Farkas for Calgary Campaign. In addition, by clicking the box below, you waive all legal rights to sue or claim compensation from Farkas for Calgary Campaign related to COVID-19. *
Required
A copy of your responses will be emailed to the address you provided.
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