2022 Calleva COVID Waiver & Health Screening
Please fill out for
EACH PARTICIPANT
in a Calleva Program! If you have any questions, please contact the Calleva Office at 301-216-1248
Participant Information
First Name
Last Name
Birthdate
mm/dd/yyyy
Group ID
Please select...
2022 Beauvoir 2nd Team Building/Wilderness
2022 Boys Latin 5th O/N
2022 Boys Latin 7th O/N
2022 BS Troop 204 Rappel Anapolis Rocks
2022 Bullis 6/7 Onsite Teambuilding
2022 Burgundy Farm 8th O/N
2022 Canterbury Woods 6th Challenge Course 1
2022 Canterbury Woods 6th Challenge Course 2
2022 Capitol Hill 3rd Team Building
2022 Chance Academy Water Day
2022 Chesterbrook 6th Challenge Course
2022 Chicago Waldorf Sampler
2022 College Track Challenge Course
2022 DeMatha Leadership O/N
2022 GDS 5th Challenge Course
2022 Green Hedges 4th O/N
2022 GS Troop 51132 Rock Climbing
2022 GU Wilderness Medicine Canoe
2022 Heights 5th Kayaking
2022 Holton Arms 6th Challenge Course
2022 Holy Redeemer 6th & 7th Challenge Course
2022 Janney 5th Challenge Course
2022 Lab 8th Challenge Course
2022 Langley 6th O/N
2022 Little Flower Environmental Ed
2022 Madeira Aerial Course
2022 Madeira Alumni Reunion
2022 Madeira MOD 1 Leadership
2022 Maret 6th Challenge Course
2022 Maret 7th Split Adventures
2022 Maret 8th Madeira Adventures
2022 McLean Spring 5th & 6th Challenge Course
2022 Meadows Valley Madeira Aerial Course
2022 OLOM 7th/8th Water Day
2022 OLV 8th Challenge Course
2022 ONSE Pathways Rafting
2022 Oyster Adams 7th Rafting
2022 Park School 8th Raft
2022 Parkmont MS Challenge Course
2022 Parkmont US Challenge Course
2022 Poolesville HS Cave
2022 Roland Park 8th O/N
2022 Sacred Heart Challenge Course
2022 St Andrews Farm/Challenge Course
2022 St. Albans 8th O/N
2022 St. Francis 8th Challenge Course
2022 St. Luke 7th Challenge Course
2022 St. Patricks 5th Onsite O/N
2022 Troop 233 Caving
2022 Troop 33134 Farm/Enviro
2022 Waldorf 7th WV O/N
2022 Waldorf 8th WV O/N
2022 WIS 5th O/N
2022 WJA 6th Adventure Island
BSA Troop 3G Climb
Parent/Guardian Information
First Name
Last Name
Emergency Contact Information
Emergency Contact Name
Emergency Contact Relationship
Please select...
Friend
Extended Family
Neighbor
Other
Emergency Contact Cell Phone Number
Health Information
Does the participant have allergies that require an epi-pen and/or Benadryl? If yes, please describe
Does the participant have asthma that requires an inhaler? If yes, please explain
Is the participant currently taking any medications? (This includes any emergency medication that may need to be administered during your Fall program)
Yes
No
Medications (Include medication name, dosage, and time of day to be administered)
Are there any special considerations (behavior, psychological, special needs) that are relevant? Please specify below
Health Screening
Authorize and Confirm
Authorize and Confirm
The participant does NOT exhibit any of the following symptoms . If any symptoms are present, please have the participant evaluated by a licensed health care provider & contact Calleva for further guidance. Symptoms: Cough, Shortness of breath or difficulty breathing, Fever, Chills, Muscle Pain, New loss of taste or smell, Nausea, Vomiting, Diarrhea
The participant will not attend any Calleva program if they have tested positive for COVID-19 and have not completed their full quarantine period, as dictated by school policies in accordance with state and local CDC guidelines.
Our family is following CDC and state guidelines to limit community spread of COVID19, including any CDC recommendations following international travel, including guidance for testing
We are practicing and reinforcing CDC-recommended hygiene practice in our home.
IF the participant is not fully vaccinated and has had close contact with someone diagnosed with COVID-19, they cannot attend a Calleva program for 7 days and must check daily for symptoms
IF the participant is fully vaccinated and has had close contact with someone diagnosed with COVID-19, they must check daily for symptoms
Authorize and Confirm
Participant and/or guardian is responsible for contacting Calleva Office if any of the described health history changes
This health screening is correct as far as I know and the person herein described has permission to engage in all prescribed activities except as noted.
Calleva Covid-19 Liability Waiver and Acknowledgement and Release Agreement
Every box must be checked in order to participate in the Enrichment Program. If you have any questions please call the Calleva office 301-216-1248
This Liability Waiver Acknowledgement and Release Agreement (“Agreement”) is between Calleva Inc (“Calleva”), the customer of Calleva that has agreed to this Agreement (“Participant”), and the Parent or Guardian of the Participant (if the Participant is under the age of 18) and is made on the date indicated below.
The novel Coronavirus SARS-Cov-2 (“COVID-19”) is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in Calleva programs or accessing Calleva facilities could expose the Participant to COVID-19. Calleva in no way warrants that a COVID-19 infection will not occur through participation in Calleva programs of accessing Calleva facilities.
AGREEMENT OF RELEASE AND INDEMNITY; NO LIABILITY: I (as the Participant (and their Parent or Guardian if under the age of 18) acknowledge and agree that: Calleva has made no representation or warranty regarding COVID-19; and Calleva shall not undertake responsibility, nor shall it be liable for the actions of me (the Participant) or any party regarding COVID-19. I (as the Participant or their Parent or Guardian if under the age of 18) further acknowledge and agree that Calleva and its officers, employees, staff, agents, servants, the owner of the venue of any part of the program, sponsors, or independent contractors shall not be responsible for any loss, costs, damages, consequential or punitive, or liability incurred by Participant of any nature including, but not limited to, those arising from any form of negligence, gross negligence, strict liability, reckless misconduct, intentional torts, personal injury, or criminal activity; and I (as the Participant or their Parent or Guardian if under the age of 18) waive my right to seek such legal redress for these causes of action. Participant (and their Parent or Guardian if under the age of 18) shall indemnify, defend, and hold Calleva, its officers, employees, staff, agents, the owner of the venue of Calleva’s program and events, servants, sponsors, or independent contractors harmless from and against all liability, whether intentional or otherwise, in connection with or arising from his or her participation in the program and events including, but not limited to, any claims of a breach of this Agreement.
ACKNOWLEDGEMENT OF RISKS: By participating in any Calleva’s programs or events, I (as the Participant or their Parent or Guardian) acknowledge that there is an element of risk in regarding COVID-19, and I (as the Participant or their Parent or Guardian) acknowledge and agree that there are dangers and rigors imposed by such programs and events regarding COVID-19. Knowing and understanding these risks, I (as the Participant or their Parent or Guardian) agree to fully assume all risk of illness, injury or death, and release and hold harmless Calleva, its officers, employees, agents, servants, independent contractors, vendors and suppliers from all actions, claims or demands for damages for personal injury, consequential or punitive damages, costs or expenses resulting from any issues related to COVID-19. I (as the Participant or their Parent or Guardian) understand that the Participant has the option to cease participation in any program and events if the Participant feels unsafe. The Participant further agrees to bear the expense of voluntarily withdrawing or ceasing participation in any program and events before it is concluded.
I (as the Participant or their Parent or Guardian) acknowledge and agree that the Participant (and their Parent or Guardian if under the age of 18) was provided with this Agreement prior to the Participant’s attendance at any of the program or events, and that Participant (and their Parent or Guardian if under the age of 18) had the option to forgo the program and events without agreeing to the terms in this Agreement.
I (AS THE PARTICIPANT OR THEIR PARENT OR GUARDIAN) HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND THAT IT CONTAINS, AMONG OTHER THINGS, A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW OF CALLEVA, ITS OFFICERS, EMPLOYEES, AGENTS, SERVANTS, INDEPENDENT CONTRACTORS, VENDORS AND SUPPLIERS, AND CONSTITUTES A LEGALLY BINDING CONTRACT BETWEEN ME AND CALLEVA. MY ELECTRONIC SIGNATURE BELOW IS OF MY OWN FREE WILL AND I (AS THE PARTICIPANT OR THEIR PARENT OR GUARDIAN) AGREE TO ALL STATED CONDITIONS, RELEASES AND LIMITATIONS OF LIABILITY.
Calleva Covid-19 Specific Agreements
Every box must be checked in order to participate in a Calleva Fall Program. If you have any questions please call the Calleva office 301-216-1248
Masks will be worn according to county and individual school guidelines
Participants will be asked to follow all protocols instated by their school or associated group. This includes distancing, health screenings, and mask policies
Guardian Signature
Date
mm/dd/yyyy
Contact Information