COVID-19 Entry Form
COVID-19 SAFETY INFORMATION:
While participating in events held or sponsored by the Pure Heart Foundation, “social distancing” must be practiced and face coverings worn at all times to reduce the risks of exposure to COVID-19.  Because COVID-19 is extremely contagious and is spread mainly from person-to-person contact, Pure Heart Foundation has put in place preventative measures to reduce the spread of COVID-19.  However, Pure Heart Foundation cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with COVID-19.

All  visitors must complete this pre-screening questionnaire and thermometer check prior to entering any Pure Heart Foundation building.
Sign in to Google to save your progress. Learn more
Visitor Full Name *
Visitor Contact Number *
Visitor Email, please add N/A if not applicable *
In the past 24 hours, have you had one of the following symptoms unrelated to a pre-existing medical condition: frequent cough or shortness of breath? *
In the past 24 hours, have you had TWO of the following symptoms unrelated to a pre-existing medical condition: sore throat, chills, headache, muscle pain, new loss of taste or smell? *
In the past 24 hours, have you experienced a fever of 100.4℉ or above? *
Have you been in close physical contact with someone who tested positive for COVID-19 within the past 14 days? *
I understand the electronic submission of this form effectively serves as my signature and I certify that I have accurately completed the COVID-19 Building Pre-Screening Form and will comply with the outcomes identified above. I understand I may not enter at any District building if I answered YES to any of the questions above. I acknowledge the terms above and certify that I have completed the COVID-19 screening questions and will comply with the requirements identified. *
Required
WAIVER SECTION
RELEASE AND WAIVER. I HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE ANY AND ALL LIABILITY, CLAIMS, AND DEMANDS OF WHATEVER KIND OR NATURE AGAINST PURE HEART FOUNDATION AND ITS AFFILIATED PARTNERS AND SPONSORS, INCLUDING IN EACH CASE, WITHOUT LIMITATION, THEIR DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AND AGENTS (THE “RELEASED PARTIES”), EITHER IN LAW OR IN EQUITY, TO THE FULLEST EXTENT PERMISSIBLE BY LAW, INCLUDING BUT NOT LIMITED TO DAMAGES OR LOSSES CAUSED BY THE NEGLIGENCE, FAULT OR CONDUCT OF ANY KIND ON THE PART OF  THE RELEASED PARTIES, INCLUDING BUT NOT LIMITED TO DEATH, BODILY INJURY, ILLNESS, ECONOMIC LOSS OR OUT OF POCKET EXPENSES, OR LOSS OR DAMAGE TO PROPERTY, WHICH I, MY HEIRS, ASSIGNEES, NEXT OF KIN AND/OR LEGALLY APPOINTED OR DESIGNATED REPRESENTATIVES, MAY HAVE OR WHICH MAY HEREINAFTER ACCRUE ON MY BEHALF, WHICH ARISE OR MAY HEREAFTER ARISE FROM MY PARTICIPATION WITH THE ACTIVITY.
MEDICAL ACKNOWLEDGMENT AND RELEASE. I DO HEREBY RELEASE AND FOREVER DISCHARGE THE RELEASED PARTIES FROM ANY CLAIM WHATSOEVER WHICH ARISES OR MAY HEREAFTER ARISE ON ACCOUNT OF ANY FIRST AID, TREATMENT, OR SERVICE RENDERED IN CONNECTION WITH MY PARTICIPATION IN THE ACTIVITY. *
Required
LIABILITY WAIVER. BY ATTENDING AND/OR PARTICIPATING IN THE ACTIVITY, YOU ARE DEEMED TO HAVE GIVEN A FULL RELEASE OF LIABILITY TO THE RELEASED PARTIES TO THE FULLEST EXTENT PERMITTED BY LAW.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of pure heart foundation. Report Abuse
Google Forms