Vaccination Status Form

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The following form is required of all 12 & older members of the Edmonton Keyano Swim Club. A response with supporting documents are required on or before Monday, September 20 (or your first day of training) in order to participate in any Keyano program. One submission is required for each swimmer in a family.

Email *

Swimmer First Name: *

Swimmer Last Name: *

Swimmer Group: *

Name of Parent / Guardian submitting this response (if under 18 years old):

The Alberta Restriction Exemption Program offers 3 options for members. Which option do you choose for the swimmer named on this form? (proof must be sent to vaccine@eksc.com) *

Proof of Vaccination

Proof of PCR Test within 72hrs of any practice

Documentation of a medical exemption

My swimmer is under 12 years old

I choose not to participate in Keyano programs at this time

I understand that I must now email corresponding proof of my selection above to vaccine@eksc.com. I understand that this information will be used by Keyano, in case of audit, to prove that it has duly followed the Restriction Exemption Program. *

I Understand

A copy of your responses will be emailed to the address you provided.

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