COVID-19 Volunteer Health Declaration Form

Volunteer First Name *

Volunteer Last Name *

Parent/Guardian First Name

Required for volunteers under 19.

Parent/Guardian Last Name

Phone # *

Email *

Volunteer Position *

Start Time of Shift

End Time of Shift

1. Do you or does anyone in your household have any of the following symptoms, either new or worsened (if not associated with allergies, chronic or pre-existing conditions): *

fever, chills, cough or worsening chronic cough, loss of sense of smell or taste, difficulty breathing, sore throat, loss of appetite, extreme fatigue or tiredness, headache, body aches, nausea or vomiting, diarrhea?

Yes

No

2. Have you come into close contact with someone who has tested positive for COVID-19 or who has been ordered to self-isolate in the past 14 days? *

Yes

No

3. Have you or has anyone in your household returned from travel outside of Canada (including USA) in the past 14 days? *

Yes

No

If you answered “yes” to any of these questions, or experience any of those symptoms after completing this form, contact the PdA registration desk ASAP (604 664 1636 ext. 0).

Please confirm each of the following: *

I certify that I answered the questionnaire truthfully and to the best of my knowledge or my child’s current health status

I acknowledge that Place des Arts follows the appropriate protocols to promote safety and health in their Facilities during the COVID-19 pandemic.

I certify that I have read the Place des Arts Safety Plan dated March 30, 2021 (found on the Policies and Procedure webpage on placedesarts.ca) and acknowledge that I must comply with the plan’s safety measures and protocols.

I certify that I am aware of the continually updated information provided by the BC Centre for Disease Control on how to protect myself, my family, and my community and what to do if I suspect that I have COVID-19.

Thank you for your co-operation in keeping PdA a safe space.

Please check your email for the confirmation to show at the Check-In Desk at Place des Arts (PdA) or to the PdA supervisor/teacher at any authorized satellite site hosting PdA programs.

Note: If the confirmation email does not show up in your email account be sure to check the junk/spam folder.