Submission

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YES NO

Are you experiencing any symptom of illness such as: cough shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell?

YES NO

Have you travelled internationally within the last 14 days?

YES NO

Do you live, work or have travelled to a COVID-19 hot spot location in the last 14 days?

YES NO

Do you believe you have been exposed to someone with a suspected and/or confirmed case of COVID-19?

YES NO

Are you currently subject to self-isolation or quarantine obligations as a result of being unwell; a pending COVID-19 test result; or for any other reason?

YES NO

Does your attendance at this event directly contravene any ACT Public Health rules and/or restrictions?

I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending the Brindabella Dance Festival?:

I understand that the risk of exposure extends to anyone with whom I have regular close physical contact, including members of my household?:

I voluntarily attend the Brindabella Dance Festival and acknowledge that I must comply with all set procedures to reduce the spread of COVID-19 while attending this event?:

I accept sole responsibility for any injury or illness 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?:

I hereby release, covenant not to sue, discharge, and hold harmless the Brindabella Dance Festival Inc., its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, or expenses of any kind?:

I have read and agree to the privacy policy and consent to my information being sent to/stored at covidpass.com.au on behalf of Brindabella Dance Festival.

Covid-19 Disclaimer: I consent to my details being collected for the purpose of Covid-19 contact tracing as required by applicable law. I understand, the information I enter will be purged at 56 days (QLD) and 28 days (Other states).

Thank you for doing your part to help contain the spread...