Covid-19 Waiver Form, Summer Skills Development (Stix n Pix)

Print Covid-19 Waiver Form
Participants 18 years of age and under are considered a "Minor" and MUST have an "Parent/Guardian" complete form before you attend your FIRST StixnPix Development Session. THIS ONLINE FORM to be completed online before each session you attend. Thankyou. "Adults" over the age of 18 that are attending the Facility or Participating in the StixnPix Programming MUST also complete the form. FORM MUST BE COMPLETED BEFORE EACH SESSION. Any questions, please contact General Manager Will Wall - [email protected]
Player Information
Please provide information about your specific player that is registering for Tryouts
  1. dd/mm/yyyy
  2. select the date/time your attending session
  3. fever greater than 38.0 C
  4. or difficulty breathing?
General Information
Please complete general information to ensure all participants are properly registered for StixnPix Development Skates
  1. first and last
  2. Secondary contact information
  3. Example: ###-###-####
  4. Example: ###-###-####
  5. Example: [email protected] Your submission will be sent to this address.
  6. to be copied on communication for player(s)
  1. I, confirm that I have read the information above and my answers are correct and the Self Declarations Form.  If my health status was to change, I will contact Norfolk Health Department immediately.

  2. Electronic Signature Concent:

    1. COVID-19 can be transmitted by asymptomatic people and the statements made by members contained in this document cannot provide certainty that COVID-19 will not be transmitted.  StixnPix Programming and the Norfolk County Facilities are taking steps to impose and enforce appropriate protocols to keep you and other members safe, but there can be no assurance that COVID-19 will not be contracted.  This is a risk that each member must assess themselves, and if you choose to come to the StixnPix Programming and/or Norfolk County Facilities, you assume the risk of either contracting COVID-19 or transmitting it to others.

    2.  StixnPix and Norfolk County Facilities are not responsible for any illness, injury, property damage, expense, loss of income, damage or loss of any kind suffered by you, including should you contract COVID-19 during, or as a result of, your use of the facilities or programming, caused in any manner whatsoever including but not limited to, the negligence of the StixnPix programming, facilities, its owners, employees, directors and members.

    3.  You here by declare that prior to any visit toe the facilities, neither you, or anyone in your household have experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing).  If you or anyone in your household experience any cold or flu-like symptoms after submitting this form, you will not visit the facilities or participate in StixnPix programming for a minimum period of 14 days after the cold or flu-like symptoms have completely gone away.

    4.  You hereby declare that you or any member of your household have not been to, traveled to, visited or had a lay-over in any country outside 
    Canada in the past 10 days.  If you or anyone in your household travels to any country outside Canada after submitting this form, you will not visit the facilities or attend StixnPix programming for a minimum period of 14 days after the date of return to Canada.

    5.  You acknowledge that you have read this Agreement and understand it.  You have had the opportunity to review this Agreement and you acknowledge that you have executed this Agreement voluntarily and agree to be bound by this Agreement.  You further acknowledge that this Agreement is binding upon yourself, your heirs, spouse, children, parents, guardians, executors, administrators, and legal or personal representatives.
  3. Comments on equipment, Medical Conditions, Allergies...
Human Validation