COVID-19 Self-Certification Health Questionnaire and Voluntary Waiver and Release of Liability

Anyone entering the building must complete this form once per day.

Contact Information

First Name *

Last Name *

Phone *

Reason for Attending (select from the list below) *

Email Address *

Acknowledgement of The Skating Club of Boston's COVID-19 Policies

Health Questionnaire *

	Yes	No
Have you had close contact with an individual diagnosed with COVID-19? (Close contact is defined as living in the same household, caring for, being within 6 feet of, or coming into direct contact with the secretions of a person who has tested positive for COVID-19.)	Yes	No
Have you been asked to self-isolate or quarantine by a doctor or public health official?	Yes	No
Have you been on an airplane in the last 7 days?	Yes	No

Acknowledgement *

	Yes	No
Do you agree to wear a face mask inside the facility?	Yes	No
I have read, understand, and agree to follow the Club's COVID-19 Safety Protocols (Updated January 21, 2021).	Yes	No

Voluntary Waiver and Release of Liability

Using the measures and guidelines provided by the Commonwealth of Massachusetts, U.S. Figure Skating, and the U.S. Rinks Association, I understand that The Skating Club of Boston has put in place enhanced health and safety measures to reduce the spread of COVID-19. I also understand that the Club cannot guarantee that I or my child(ren) will not become infected with COVID-19. By signing this agreement and visiting and using the facilities of The Skating Club of Boston, I acknowledge that an inherent risk of exposure to COVID-19 exists in any public place where people are present.

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Club, and that such exposure or infection may result in extreme illness, permanent disability, and possibly death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Club may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Club employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Club or participation in Club programming (“Claims”).

On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold
harmless the Club, its employees, agents, and representatives, of and from the Claims, including all
liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I
understand and agree that this release includes any claims based on the actions, omissions, or
negligence of the Club, its employees, agents, and representatives, whether a COVID-19 infection
occurs before, during, or after participation in any Club program. I understand that falsifying responses will result in a $250 fine per day and/or possible suspension from member privileges. *

I have read and agree to the above Waiver and Release of Liability

Name of Participating Member *

Signature of Skater (Parent or Guardian if under 18) *

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COVID-19 Self-Certification Health Questionnaire