Visitor & Volunteer Acknowledgement

New Hope for Kids has the health and safety of every person who works, visits or volunteers on our premises as a top priority. In order to reduce the risk of spreading COVID-19, we ask that you complete this questionnaire. For the safety of other visitors and volunteers, as well as staff, please be truthful in your responses.

1. Have you been fully vacinated?*

Yes
No

2. Within the last 14 days, have you been in direct contact with a person confirmed to be positive with a COVID-19 test?*

Yes
No

3. Within the last 14 days, have you been in close contact with anyone experiencing any of the following symptoms? fever, cough, shortness of breath, sore throat, body aches, lack of taste or smell.*

Yes
No

4. Within the last 14 days, have you experienced any of the following symptoms? fever, cough, shortness of breath, sore throat, body aches, lack of taste or smell.*

Yes
No

5. Have you previously been asked to self-isolate or self-quarantine?*

Yes
No

If yes, please indicate date(s)

6. I agree to have my temperature taken upon arrival at New Hope for Kids.*

Yes
No

7. I am 18 years or older.*

Yes
No

8. I agree to adhere to the following while on New Hope for Kids property, or at a New Hope for Kids event/activity off-site: Follow current CDC guidelines https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/index.html ; Adhere to mask mandates and other Covid-19 protocols established by venues, businesses, and/or sponsors at New Hope for Kids events/activities, even if not required by the government ; Adhere to local government ordinances and executive orders*

Yes
No

9. I hereby authorize New Hope for Kids and any project sponsor affiliated with New Hope for Kids to use, reproduce, and/or publish all written and/or visual materials including photographs and artwork that may pertain to me, my family, and any minor children.*

Yes
No

RELEASE OF LIABILITY*

I hereby agree to release and hold harmless New Hope for Kids, Inc., including its agents, employees, affiliates, successors, and assignees (“New Hope for Kids”) from and against any and all liability, claims, demands, suits, and causes of action whatsoever arising, directly or indirectly, out of any damage, loss, injury or illness (including COVID-19-related occurrences) to me or my family, my property, or my death, arising from or in relation to any activity engaged in with New Hope for Kids, arising from the negligence or some other fault, direct or indirect, active or passive, of New Hope for Kids.

By signing this release, I acknowledge that I have had the opportunity to seek counsel and have completely read and fully understand this release and agree to be bound by it.

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Cell Phone Number*

Signature*

Date*

Parent / Legal Guardian

If this release is obtained from an individual under the age of 18, the signature of that individual’s parent or legal guardian is also required.

Parent / Legal Guardian Cell Phone

Date

Name of event or staff member I will be attending/meeting:*

Date of meeting/service:*

Scheduled time of arrival:*

:

I acknowledge that this form is only valid for 24 hours prior to my arrival at New Hope for Kids.