I, the visitor, submit this visitation agreement for consideration as the DESIGNATED VISITOR for the Elder stated above. Upon approval, I agree that I alone will have visiting privileges granted unto me; there will be no substitutions of any other persons made in my absence. I also understand that all visitation agreements must be approved by the Kinsmen Lodge CEO prior to the commencement of any visitations which are subject to the following conditions:
I will not visit if a COVID-19 OUTBREAK has been declared at Kinsmen Lodge.
I will not visit if the Elder I am visiting has been placed on isolation after exhibiting any COVID-19 symptoms or due to
any additional safety precautions deemed necessary by the Kinsmen Lodge Leadership Team.
I will not visit if I am sick, exhibiting any COVID-19 symptoms, or have been required to self-isolate under the directive
of public health authority officials.
I will not visit if I have travelled outside of Canada in the last 14 days – including the United States of America (USA).
I will not bring outside food onto the Kinsmen Lodge premises. Gift items may be brought to the Front Vestibule
where they will be held for 72 hours prior to delivery to the Elder.
I will not disturb other Elders, other visitors or any staff during my visits and will avoid involvement with care routines.
I understand visits will only be scheduled in advance with a minimum of seven (7) days’ notice.
Note: Walk-ins/drop-ins will not be accommodated under any circumstances.
I understand that, at this time, visits will only be scheduled for a duration of twenty (20) minutes between the hours
of 9:20 AM - 4:00 PM.
I understand that I will only enter and exit via the designated access area as directed by the Visitation Monitor.
I understand that I will be permitted to arrive at the designated visitor entrance no more than ten (10) minutes prior
to the visitation start time to complete the COVID-19 visitor screening. Note: If visitor screening has not been done
beforehand, then the time taken to complete this process will be subtracted from the scheduled visitation time.
I understand that I may be asked to provide photo ID as proof of my identity and will make it available to the
Visitation Monitor, upon request. Note: Failure to do so may revoke visitation privileges for that day.
I understand there are scheduling constraints to visitation and will leave promptly when my reserved time is over.
I understand that I will not be able to use the washroom facilities within Kinsmen Lodge.
I must pass the COVID-19 visitor screening at the designated visitor entrance before any visitation can occur.
I will report to the Visitation Monitor if I exhibit any COVID-19 symptoms at any time during my visit. Note: If the
Visitation Monitor observes the occurrence of any COVID-19 symptoms during the visit, the designated visitor will be
asked to immediately leave the Kinsmen Lodge premises.
I will wash my hands or use an alcohol-based hand rub before and after my visit.
I will provide and wear a face mask – no exceptions – for the duration of my visit and will not remove it until I have
left the Kinsmen Lodge premises. Note: If you are unable to provide your own face mask upon entrance, one can be
purchased from the Visitation Monitor at $2.00 each per mask.
I will maintain proper social distancing for the duration of my visit and will not engage in any form of physical contact.
I will only remain in the designated visitation area. Note: Visits will be monitored at a distance to ensure proper
safety protocols are being observed by both the Elders and their designated visitors.
By submitting this electronic form below, I agree that if I am found to be non-compliant with any of the terms of safety listed above or
deemed inappropriate by staff, my visitation privileges may be revoked. Note: All visitation agreements and conditions are subject to review and revision by the Kinsmen Lodge CEO at any time.