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ALPHA KAPPA ALPHA SORORITY, INCORPORATED COVID-19 SCREENING QUESTIONNAIRE

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ALPHA KAPPA ALPHA SORORITY, INCORPORATED
®
COVID-19 SCREENING QUESTIONNAIRE & WAIVER
This form must be completed by all participants before the in-person activity.
PLEASE PRINT LEGIBLY.
First Name: ____________________________________________________________
Last Name: ____________________________________________________________
Email Address: _________________________________________________________
Mobile Number: ________________________________________________________
Temperature*: ____________
*Temperature will be taken by the sponsoring chapter/event organizers prior to entry.
Are you fully vaccinated?
_____ Yes
_____ No
*Proof of vaccination is required before entry will be permitted.
Have you been diagnosed positive with COVID-19 within the last 14 days?
_____ Yes
_____ No
*If YES, please provide documentation of a subsequent negative test.
Have you experienced any of the following symptoms: fever, shortness of breath or difficulty breathing, runny
nose, loss of taste or smell, dry cough, sore throat, chills, muscle pain, headache, diarrhea or vomiting?
_____ Yes
_____ No
Have you been exposed to someone with a suspected or confirmed case of COVID-19 within the last 14 days?
_____ Yes
_____ No
*If YES, please provide documentation of a subsequent negative test.
Have you traveled internationally within the last 14 days?
_____ Yes
_____ No
If participant answers “YES” to any of the questions above, immediately notify the sponsoring
chapter/event organizers and await further instructions before permitting entry.
_____________________________________________ ____________
Participant/Parent/Guardian’s Signature Date
*If the participant is minor under 18 years of age, the parent/guardian must complete and sign this
form on the minor’s behalf and indicate relationship to the minor.
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WAIVER OF LIABILITY AND RELEASE
I hereby release and agree to hold Alpha Kappa Alpha Sorority, Incorporated harmless from and waive
any and all causes of action, claims, demands, damages, costs, expenses and compensation for illness
or death arising out of exposure to COVID-19 that may be caused by any act or failure to act during
my participation in this event or activity on behalf of myself, my heirs, and any personal
representatives. I understand that this Waiver discharges Alpha Kappa Alpha Sorority, Incorporated,
its employees or representatives from any liability or claim that I, my heirs, or any personal
representatives may have against the sorority arising out of exposure to COVID-19. The Waiver of
Liability and Release extends to members of the Board of Directors, employees, and participating
members of Alpha Kappa Alpha Sorority, Incorporated.
By initialing below, 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 participating in this activity or event or
other Alpha Kappa Alpha Sorority, Incorporated activities and that such exposure or infection may
result in personal injury, illness, permanent disability, and death. Initials: _________
Attestation
By voluntarily affixing my initials and signature to this Waiver of Liability and Release, I attest that I
have read and fully understand this statement in its entirety and that my participation in this event is
strictly voluntary and not under threats, duress or coercion by anyone.
_____________________________________________
____________
Participant/Parent/Guardian’s Signature
Date
Rev. 102021
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ALPHA KAPPA ALPHA SORORITY, INCORPORATED COVID-19 SCREENING QUESTIONNAIRE

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Completed 3 January 2022

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