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SRC Health and Wellness Self-Declaration Form
This declaration is for the entirety of the aforementioned event. If, during the course of the event, your answers
to any of the questions below change it is your responsibility to inform Club and/or Show Management
accordingly and to complete an updated Self-Declaration Form.
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* Indicates required question
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Address
*
Your answer
Email Address
*
Your answer
Cell Phone Number
*
Your answer
Event Name
*
2021 Spring Hunter Jumper Show
2021 2&3/4 Phase
2021 Dogwood Show - July 3 & 4
Clinic
Schooling or Guest Ride
Do you understand the risks of coming into contact with other people at Southlands Riding Club during the COVID-19 global pandemic?
*
Yes
No
Do you understand that you could become infected with COVID-19 while at Southlands Riding Club?
*
Yes
No
Do you agree to waive all liability and to indemnify Southlands Riding Club, Southlands Riding & Polo Club Limited, Equestrian Canada and Horse Council of British Columbia for damages that may be incurred by as a result of any misstatement in this self-declaration?
*
Yes
No
Do you agree to monitor your own temperature each morning prior to entering the competition grounds?
*
Yes
No
To your knowledge, have you or anyone in your household had contact of any kind with someone diagnosed with COVID-19 (presumptively or confirmed) within the last 15 days?
*
Yes
No
Have you or anyone in your household experienced any cold or flu-like symptoms in the last 15 days,including, but not limited to fever, cough, sore throat, respiratory illness, shortness of breath or difficulty breathing?
*
Yes
No
Have you or anyone in your household returned from any destination outside of Canada or travelled in an airplane from any destination within the last 15 days?
*
Yes
No
Do you agree to inform Southlands Riding Club in the event that – within the 14-day period following this competition – you or someone in your household experiences any cold or flu-like symptoms for the purpose of anonymous contact tracing?
*
Yes
No
Do you understand that should circumstances arise you have a duty to Southlands Riding Club to refrain from entering the premise until a period of 15 days has passed?
*
Yes
No
Signature
*
Your answer
Date
*
MM
/
DD
/
YYYY
*If person named on this form is under the age of 18, this form must be signed by a parent or guardian, and the information below completed:
Name of person signing on behalf of minor
Your answer
Relationship to minor
Your answer
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