Pure Heart Foundation Site Entry Form

In the past 24 hours, have you or any of your accompanied minors had any of the following symptoms unrelated to a pre-existing medical condition: 1. sore throat 2. chills 3. headache 4. muscle pain 5. new loss of taste or smell 6. frequent cough 7. shortness of breath

In the past 24 hours, have you or any of your accompanied minors experienced a fever of 100.4℉ or above?

Have you or any of your accompanied minors been in close physical contact with someone who tested positive for COVID-19 within the past 14 days?

Have you or any of your accompanied minor(s) received the COVID-19 vaccine?

I understand the electronic submission of this form effectively serves as my signature and I certify that I have accurately completed the COVID-19 Site Entry Pre-Screening Form and will comply with the outcomes identified above. I understand I may not enter at any District building if I answered YES to any of the questions above. I acknowledge the terms above and certify that I have completed the COVID-19 screening questions for myself and my accompanied minors and will comply with the requirements identified.

I hereby release, waive, and forever discharge any and all liability, claims, and demands of whatever kind or nature against Pure Heart Foundation and its affiliated partners and sponsors, including in each case without limitation, their directors, officers, employees, volunteers, and agents (the “released parties), either in law or in equity, to the fullest extent permissible by law. Including but not limited to damages or losses caused by negligence, fault, or conduct of any kind on the part of the released parties, including but not limited to death, bodily injury, illness, economic loss, or out of pocket expenses, or loss or damage to property, which I, my heirs, assignees, next of kin, and/or legally appointed or designated representative, may have or which may hereinafter accrue on my behalf, which arise or may hereafter arise from my participation with the activity.

I do hereby release and forever discharge the released parties from any claim whatsoever which arises or may hereafter arise on account of any first aid, treatment, and/or service rendered in connection with my participation in the activity.

By attending and/or participating in the activity, you are deemed to have given a full release of liability to the released parties to the fullest extent permitted by law for you and your accompanied minor(s).