SURFSIDE WELLNESS CENTRE COVID-19 SCREENING QUESTIONNAIRE

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Email *

NAME *

DATE *

YYYY

ADDRESS *

TELEPHONE # *

PLEASE ANSWER THE FOLLOWING:

Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit or 37 degrees Celsius? *

Yes

Have you or anyone in your household tested positive for COVID-19? *

Yes

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days? *

Yes

Have you or anyone in your household traveled outside of Barbados in the past 21 days? *

Yes

Have you or anyone in your household traveled on a cruise ship in the last 21 days? *

Yes

Are you or anyone in your household a health care provider or emergency responder? *

Yes

Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19? *

Yes

Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19? *

Yes

To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? *

Yes

DECLARATION

(1) Do you declare the questions listed above were answered truthfully. *

Yes

(2) Do you agree to notify Surfside Wellness Centre immediately if there are any changes to the responses listed above, including but not limited to presenting with the symptoms listed above, being in close proximity with an individual that has tested positive for covid-19, or personally testing positive for covid-19. *

Yes

PLEASE ENTER YOUR FULL NAME IN THE SPACE PROVIDED BELOW AS CONFIRMATION OF DECLARATION (1) & (2) *

COVID-19 WAIVER OF LIABILITY AND INDEMNIFICATION

DATE *

YYYY

NAME *

I agree that I am personally responsible for my safety and actions while using the Surfside Wellness Centre facility. *

YES

I agree to comply with all Surfside Wellness Centre policies and rules, including but not limited to all Surfside guidelines, signage, and instructions. *

YES

DECLARATION 3: Because Surfside Wellness Centre is open for use by other individuals, I recognize that I am at higher risk of contracting COVID-19. With full awareness and appreciation of the risks involved, I, for myself and on behalf of my family, spouse, estate, heirs, executors, administrators, assigns, and personal representatives hereby forever release, waive, discharge, and covenant not to sue Surfside Wellness Centre, its board members, officers, agents, servants, independent contractors, affiliates, employees, successors, and assigns Surfside Wellness Centre release from any and all liability, claims, demands, actions and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by me related to COVID-19 whether caused by the negligence of the Released Parties, any third-party using Surfside or otherwise, while participating in any activity while on, or around Surfside Wellness Centre or while using the Surfside Wellness Centre facility.

PLEASE ENTER YOUR FULL NAME IN THE SPACE PROVIDED BELOW AS CONFIRMATION OF DECLARATION (3) *

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