Cham Shan Temple COVID-19 Visitor Questionnaire and Consent Form 新冠肺炎访客问卷和同意书
To prevent the spread of COVID-19 and reduce the potential risk of exposure, we ask that you complete a simple screening questionnaire and a consent form.  Your participation is important to help us take precautionary measures to protect you and everyone in the temple. Thank you for your time,
为防止新冠肺炎传播并减少对大众的潜在风险, 请填寫以下简单的问卷和同意书。您的参与将帮助我们采取预防措施以确保您和大众的健康。感谢您的时间。

One form for all visitors living in the same address 在同一地址居住的所有访客, 可填写一张表格。
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Name of visitor(s)/访客姓名: *
Contact number/ 联系电话: *
Email address/电邮地址 or 或 Wechat Account/微信号:   *
Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing) ?在过去的14天内, 您是否曾经出现过任何感冒或类似流感的症状 (包括发烧,咳嗽,喉咙痛,呼吸系统疾病, 呼吸困难)？ *
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?在过去的14天内, 您是否与新冠肺炎确诊者有过密切接触？ *
Have you travelled outside of Canada or have had close contact with anyone who has travelled outside of Canada in the last 14 days?在过去14天内,您曾否离开加拿大或曾与离开加拿大的任何人有密切接触？ *
I/We will wear a mask at all times when on Cham Shan Temple’s premises. 我/我们在湛山精舍范围内会一直戴上口罩。 *
If I/We are later diagnosed as having COVID-19 within 14 days after visiting Cham Shan Temple, then I/We will contact Cham Shan Temple at 905-886-6481 immediately, so that Cham Shan Temple may notify all potential persons at risk, and take necessary precautions to protect the health and well-being of all parties. 如我/我们在未来14天内被确诊为新冠肺炎患者, 我/我们将立即联系湛山精舍大殿香油台905-886-6481, 以便湛山精舍可以通知有潜在危险的人士, 并采取必要的预防措施来确保各方的健康。 *
I/We understand that despite Cham Shan Temple’s efforts, there exists an inherent risk of COVID-19 and other infections when I/we enter and/or participate in activities of Cham Shan Temple.  I/We assume full responsibility of all such risk. I/We hereby waive and release any and all claims against Cham Shan Temple, its officers, agents and employees, and agree not to sue such entities, with respect to any and all illnesses, disability, death and loss or damage to property, regardless of the cause and even if caused by negligence of Cham Shan Temple, whether passive or active.我/我们了解尽管湛山精舍做出了努力，但当我/我们进入湛山精舍和/或参加湛山精舍的活动时，仍然存在感染新冠肺炎和其他疾病的潜在风险。我/我们对所有此类风险承担全部责任，免除湛山精舍的一切责任。我/我们特此放弃对湛山精舍与其员工、义工、董事和其他有关人士的任何诉讼权利，并同意不就任何疾病、伤残、死亡和财产损失等向湛山精舍索赔，无论此等事故是否由于湛山精舍的主动或被动的疏忽行为造成。 *
Signature of visitor(s) 访客签名: *
Date of Visit 到访日期 *
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