Individual Name (print): ___________________________________________________
Individual’s Parent/Guardian ___________________________________________________
(if the individual is younger than 18 years old)
Email: ___________________________________________________
Telephone: ___________________________________________________

WARNING !
ALL INDIVIDUALS ENTERING THE FACILITY MUST COMPLY WITH THIS DECLARATION
Ontario Soccer and its affiliated districts, leagues, clubs and teams (collectively the
“Organization”) require the disclosure of exposure or illness is in order to safeguard the health
and safety of all participants and limit the further outbreak of COVID-19. This Declaration of
Compliance will be kept safely, and personal information will not be disclosed unless as
required by law or with your consent.

An individual (or the individual’s parent/guardian, if the individual is younger than 18 years old)
who is unable to agree to the terms outlined in this document is not permitted to enter the
Organization’s facilities or participate in the Organization’s activities, programs, or services.
I, the undersigned being the individual named above and the individual’s parent/guardian (if
the individual is younger than 18 years old), hereby acknowledge and agree to the terms
outlined in this document:

1) The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World
Health Organization and COVID-19 is extremely contagious. The Organization has put in
place preventative measures to reduce the spread of COVID-19 and requires all individuals
(or their parent/guardian, when applicable) to adhere to the compliance standards
described in this document.

2) The individual has not been diagnosed with COVID-19. OR If the individual was diagnosed
with COVID-19, the individual was cleared as noncontagious by provincial or local public
health authorities.

3) The individual has not been exposed to a person with a confirmed or suspected case of
COVID-19. OR If the individual was exposed to a person with a confirmed or suspected
case of COVID-19, the date of exposure was more than 14 days prior to the date this
Declaration of Compliance was signed.

4) The individual is attending or participating voluntarily and understands the risks
associated with COVID-19. The individual (or the individual’s parent/guardian, on behalf of
the individual (when applicable)) agrees to assume those risks, including but not limited to
exposure and being infected.

5) The individual has not, nor has anyone in the individual’s household, experienced any signs
or symptoms of COVID-19 in the last 14 days (including fever, new or worsening cough,
fatigue, chills and body aches, respiratory illness, difficulty breathing, nausea, vomiting or
diarrhea, pink eye, or loss of taste or smell).

6) If the individual experiences, or if anyone in the individual’s household experiences, any
signs or symptoms of COVID-19 after submitting this Declaration of Compliance, the
individual will immediately isolate, notify the Organization, and not attend any of the
Organization’s facilities, activities, programs or services until at least 14 days have passed
since those symptoms were last experienced.

7) The individual has not, nor has any member of the individual’s household, travelled to or
had a lay-over in any country outside Canada in the past 14 days. If the individual travels,
or if anyone in the individual’s household travels, after submitting this Declaration of
Compliance, the individual will not attend any of the Organization’s facilities, activities,
programs or services until at least 14 days have passed since the date of return.

8) The individual is following recommended guidelines, including but not limited to practicing
physical distancing, trying to maintain separation of six feet from others, adhering to
recognized hygiene best practices, and otherwise limiting exposure to COVID-19.

9) The individual will follow the safety, physical distancing and hygiene protocols of the Organization.

10) This document will remain in effect until the Organization, per the direction of the provincial
government and provincial and local public health authorities, determines that the
acknowledgements in this Declaration of Compliance are no longer required.

11) The Organization may remove the individual from the facility or from participation in the
activities, programs or services of the Organization at any time and for any reason if the
Organization believes, in its sole discretion, that the individual is no longer in compliance
with any of the standards described in this document.

Signature: _____________________________________ Date: ___________________
Individual (If 13 and over)

Signature: _____________________________________ Date: ___________________
Parent/Guardian (if the individual is younger than 18 years old)