YM - Participant COVID Waiver

All participants must complete a COVID waiver in adition to the participation permision required of youth participants.

NOTE: We are experiencing an error with this form. If you get an error at submission, do not re-submit. We are receiving the forms even though people are getting an error. We are trying to sort this out. In the meantime, please just complete the form once for each participant. Thank you for your patience!

EVENT NAME & DATE
Please note the Youth Ministry event and date you are signed up for in the box below. *
Participant Information
Participant Name Participant Name * First Last
Birth Date Birth Date * / MM / DD YYYY
* Parent/Guardian Information (Required if participant is a minor.) * Parent/Guardian Information (Required if participant is a minor.) First Last
ASSUMPTION OF RISK
The novel coronavirus, COVID-19, has been declared a worldwide pandemic and is contagious. As a result, in order to resume Youth Ministry activities (“Youth Ministry”), the Catholic Diocese of Arlington has established essential health and safety measures at the Catholic parish named above ("Parish"). The Parish has put in place reasonable preventative measures and standards of behavior, consistent with guidelines issued by the Centers for Disease Control and Prevention (“CDC”) and state and local public health guidance, to reduce the spread of COVID-19 in Youth Ministry activities. Even with implementation of health and safety protocols, however, the Diocese and Parish cannot guarantee that you or your child(ren) will not become infected with COVID-19, and participation in Youth Ministry activities could increase your risk and/or your child(ren)'s risk of contracting COVID-19. Any interaction with others includes possible exposure to, and illness from, communicable diseases including COVID-19 and influenza. I understand that Youth Ministry activities are not mandatory. By returning to in-person Youth Ministry activities, I give my informed consent for me or my child(ren) to participate and assume responsibility for the above-noted risks. I willingly agree that my child(ren) and/or I will comply with the health and safety protocols established by the Parish, and will take all reasonable and necessary additional precautions to protect against communicable diseases while on Parish premises, not only for our own benefit but for the benefit of others with whom we may come into contact. We agree that, if we observe any objects, practices or procedures we believe to be hazardous while on Parish premises, we will remove ourselves from the location of such hazard and bring it to the attention of Parish administration immediately.
I have read the assumption of risk. *

I have read the assumption of risk. Yes.
LIABILITY WAIVER
By signing this agreement below, I acknowledge the contagious nature of COVID-19 and that my child(ren) and/or I may be exposed to or infected by COVID-19 by participating in in-person Youth Ministry activities, and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I understand that the risk of becoming exposed to or infected by COVID-19 at the above-named Parish may result from the actions, omissions, or negligence of myself, my child(ren) or others, including, but not limited to Diocesan or Parish administrators, employees, volunteers, and other program participants and their families. I further agree on behalf of myself and/or my child(ren) named herein, and our respective heirs, successors, and assigns, to fully and forever release, defend, indemnify, and hold harmless the Catholic Diocese of Arlington, the named Parish, their clergy, administrators, employees, agents, members and volunteers ("Indemnitees") from any and all claims, damages, demands, and causes of action, present or future, known or unknown, anticipated or unanticipated, in any way related to exposure to COVID-19 while participating in Youth Ministry activities, including but not limited to any claims of negligent exposure. This includes claims that arise from my own and others’ acts, actions, activities and/or omissions, excepting only those which arise solely from the gross negligence, recklessness or intentional torts of Indemnitees. I will defend and indemnify Indemnitees with respect to any released claim, including but not limited to damages, costs and attorney’s fees.
I have read the liability waiver. *

I have read the liability waiver. Yes.
RESPONSIBILITY FOR HEALTH SCREENING
By execution of this Statement, I affirm that my or my child(ren)’s presence at named Parish on any day constitutes an affirmative representation on my part that I/we have performed the required health screening below and affirm that the responses to all questions are NO. SCREENING QUESTIONS “YES or NO, neither I nor my child(ren) have any of the following:” • A fever of 100.4°F. (38°C.) or higher or a sense of having a fever during the past 72 hours • New or unexpected cough that cannot be attributed to another health condition • New shortness of breath or difficulty breathing that cannot be attributed to another health condition • New chills that cannot be attributed to another health condition • A new sore throat that cannot be attributed to another health condition • New muscle aches that cannot be attributed to another health condition or specific activity (such as physical exercise) • New loss of taste or smell • Nausea, vomiting or diarrhea “YES or NO, in the past 14 days, neither I nor my child(ren) have done any of the following:” • Cared for or had other close contact with a person suspected or confirmed to have COVID-19 • Travelled internationally • Currently living with a person who has exhibited symptoms of COVID-19 or is currently under quarantine due to close contact with a person suspected or confirmed to have COVID-19 I understand that on any day when anyone in our household answers YES to any of the required health screening questions above, I and/or my child(ren) are not permitted to participate in in-person Youth Ministry activities.
I have read the responsibility for health screening. *

I have read the responsibility for health screening. Yes.
NEED TO INFORM & QUARANTINE
I further understand, in the event that I/my child is suspected or confirmed positive with COVID-19 or has come in close contact with a person suspected or confirmed positive with COVID-19, I/my child will need to follow the CDC’s guidance for isolation or quarantine as appropriate. Information is available at www.cdc.gov. I agree to inform the Parish administration as soon as possible, but no later than 1 business day, after learning of my/my child’s suspected or confirmed positive case of COVID-19 and/or the need to quarantine due to close contact with a person suspected or confirmed positive for COVID-19. I understand that I/my child may not return to in-person Youth Ministry activities until approved by Parish Administration. Approval will be based on confirmation that the CDC's criteria to discontinue home isolation or quarantine has been met. For details reference: For those suspected or confirmed positive: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/end-home- isolation.html For those quarantining due to close contact: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html
I have read the terms to inform and quarantine. *

I have read the terms to inform and quarantine. Yes.
AUTHORIZATION & INFORMED CONSENT
I hereby authorize the Parish to enforce such other reasonable measures and directives as may be deemed necessary by the Bishop of the Diocese of Arlington, its Office of Youth, Campus, and Young Adult Ministries or the Parish leadership. I further understand that, in the event that it becomes necessary that events or programs should be cancelled or administered via electronic media, I will not be entitled to a refund of any of my fees. This Agreement has been prepared in the English language, and the English version thereof shall prevail and be binding in the event of any inconsistency even though a Spanish or other language translation may also be prepared. By execution of this Agreement, I understand and agree to the foregoing terms and conditions.
Please sign in the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

YM - Participant COVID Waiver

YM - Participant COVID Waiver

Participant Information