Lakeshore Recreation

Facility Check-in Form

Participant Name

Participant Age

Parent/Guardian Name

Date

Time of Skate/Event

Location

Rock Rink (A)

Shuren Rink (B)

Rink C (C)

Libro Centre (Woodslee)

Have you or anyone near you travelled outside of Canada in the last 14 days? (Except if traveling outside of Canada for work)

Yes

No

Muscle aches, fatigue, headache, sore throat, runny nose or diarrhea?

Yes

No

Does anyone near you have Covid-19 (e.g., someone in your household or workplace)?

Yes

No

Are you in close contact with a person who is sick with respiratory symptoms (for example, fever, cough or difficulty breathing) who recently travelled outside of Canada?

Yes

No

Phone Number

Email Address

Release - The undersigned agrees to the waiver and that, in using the Atlas Tube Centre he/she does so entirely at their own risk and hereby releases Lakeshore, its staff and suppliers from any and all claims.

I agree to the following...

By ticking this box and clicking the submit button, I agree and consent to the terms of:

That this information you provided is accurate and truthful.
That this data can be shared with the local health unit

Signature

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Facility Check-in Form

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