COVID-19 YOUTH PARTICIPATION FORM

Please read below and acknowledge that you will not allow your youth to participate if you answer yes to any of these questions.

Covid-19 Screening Questionnaire
● Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or
greater than 100 degrees Fahrenheit?
● Have you or anyone in your household been tested for COVID-19?
● Have you or anyone in your household traveled in the U.S. or outside of the US in the past 21 days?
● Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?
● Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
● To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?
● Within the past 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?

Assumption of Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus (“COVID-19”) has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

St. Thomas Chaldean Catholic Church (“St. Thomas”) has put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, participation in parish activities or events (including, but not limited to Adult Faith Formation, Youth Groups, Catechism, or Communion programs) could increase your child(ren)’s or your risk of contracting COVID-19.

By signing this agreement, 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 participating in parish activities or events at St. Thomas and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at St. Thomas may result from the actions, omissions, or negligence of myself and others, including, but not limited to, School 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 participation in any parish activity or event at St. Thomas (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless St. Thomas and the Eparchy of St. Thomas the Apostle, and all of their current, former, and future agents, representatives, religious and employees and related entities (collectively, “the Eparchy”) 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 Diocese, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after or participation in any parish activity or event.