Event, Date, and Times:

__________________________________________________________________________

Name(s) and grades of students:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Name of emergency contact, address, and phone number(s):

___________________________________________________________________________

NOTES:  as part of our UUCC covenant, we should take precautions to ensure the safety of each other!

-A signed copy of this form is required for participation in this event

-Attendees may not enter any UUCC building before, during, or after this event

-All attendees must wear face masks and practice social distancing during the duration of the event

-No attendees may share food or beverages during the duration of this event

-At least 2 approved adult chaperons must be present (having passed background checks)

-Adult chaperons must keep a list of all attendees (regardless of how briefly they are with the group)

-Adult chaperons must document any signs of illness, including but not limited to fever or chills, chest congestion or difficulty breathing, cough, loss of taste or smell, headache, etc. in any attendee

-Anyone who attends a UUCC offsite event and is later diagnosed as having Covid should notify the UUCC Administrator as soon as possible.

I hereby give my consent for the student(s) listed above to attend this event:

___________________________________________________________________________

(printed name)             (relationship)                           (signature)