KAD Outdoor Visitation Acknowledgement Form

Thank you for completing this form prior to your visit. If you are unable to print and bring this form with you, please plan to arrive in advance of your scheduled visit so that we can provide you a blank form to complete. We look forward to seeing you again!


Name of Resident you are here to visit: ________________________________

Visitor #1: Name: _________________________________________

Contact #: _______________________

Address: __________________________________________________________________________________

I have read and understand Visitor Guidelines and Consent to COVID-19 Questionnaire: YES NO

Signature: __________________________________________________ Date: ________________________

Visitor #2: Name: ______________________________________

Contact #: _______________________

Address: __________________________________________________________________________________

I have read and understand Visitor Guidelines and Consent to COVID-19 Questionnaire: YES NO

Signature: _____________________________________________

Date: ________________________

Acceptance of Visitor Guidelines and Consent for COVID-19 Questionnaire and temperature check are required for all visitors.

A signed copy of Visitor Guidelines will be maintained for future visits. Future visits will only require Assessment/Check-In, unless additional guidelines need to be added for safe visit.



COVID-19 spreads easily and is believed to be spread primarily through airborne droplets from an infected person’s speech, coughs, and sneezes, and possibly through contaminated surfaces. When enough droplets from the air enter the mouth or nose of another person, that person becomes infected. People with and without known symptoms can spread the virus to others, person to person.

People with underlying health conditions have a higher risk for an adverse outcome from a COVID-19 infection. These could include: being older than 60 years old, diabetes, severe obesity, known respiratory conditions, renal disease, known cardiac disease, including hypertension and immunocompromised conditions (HIV, cancer, post-transplant, Prednisone treatment), and other underlying health problems.

Understanding risk, but also recognizing benefits of visits with loved ones to reduce feelings of social isolation and loneliness, Kingston will begin OUTDOOR VISITATION with stringent visitation policies to mitigate the risks to our population.

CONDITIONS UNDER WHICH VISITATION MAY BE CHANGED: Kingston will continue to monitor our ability to meet safe environmental conditions. Visitation is subject to change if Kingston is not able to maintain risk mitigation strategies to ensure the safety of our residents, staff, and visitors. VISITATION MAY BE LIMITED under CAUTIONARY discretion of management and STOPPED if environmental or resident risk increases individually or community-wide.

Residents under COVID-19 fourteen (14) day observation period or who are ACTIVE COVID-19 are not eligible for visitation.

SCHEDULING OF VISITS: All visits will need to be scheduled. Please call 260-490-5111 or schedule on-line by clicking here.

VISITING HOURS: Monday through Friday 10AM-12PM and 2PM-4PM

FREQUENCY OF VISITS: Visits will begin slowly and increase with time. To begin, we are asking that you not schedule more than 1 visit per week.


PARKING: Front parking

VISIT LENGTH: Each visitor will be required to follow a visitation time limit of 45 minutes. Time requirements are necessary to allow for sanitation of visiting areas and accommodation of visitation for all residents and guests.

NUMBER OF VISITORS: Limit of 2 assigned visitors per resident

VISITOR ARRIVAL: All visitors should wait in vehicle until called. You may also call 260-490-5111, if you arrive and are not guided by Kingston staff to your visitation area. All visitors must be at least 12 years of age. No pets allowed at this time.

NUMBER OF VISITORS: Limit of 2 assigned visitors per resident. Visitors must be 12 years of age. Sorry, no pets are allowed at this time.

Please wait in your automobile and we will call you when we are ready for your visit with your loved one. Please plan to arrive 10 minutes early. Once we call you to let you know we are ready, please plan to:

  1. Possibly relocate your automobile to an area closer to the visiting tent.
  2. Please have this Visitor Guideline Consent form and our Health Screen filled out. (If you don’t have access to printing documents prior to your visit we will provide you with blank forms).
  3. Please bring your own face mask and wear upon arrival. Kingston is unable to provide face masks to guests.
  4. Staff will escort you to the tent or visiting area.
  5. Staff member will take your temperature at the tent or visiting area.
  6. Please use hand sanitizer supplied at the entrance to the tent/visiting area.
  7. Visit will be timed according to schedule.

Please be aware we do not have public facilities available to visitors; therefore, please use restroom prior to visit/arrival.

SUPERVISION: Staff will bring your loved one to the designated area for visitation. For the safety of our residents, staff, and visitors, it is necessary for a Kingston employee or volunteer to supervise all visitations to ensure compliance with risk mitigation strategies.

Residents and visitors may not leave the visiting area and must maintain 6 feet social distancing at all times. Residents who leave the area may be subject to a 14-day quarantine upon returning to the area or to the facility.

GIFT ITEMS: No food/beverage/tobacco/vaping shall be permitted during visitation. All items brought from home for a resident must follow Kingston’s policy for allowable items, including location of drop off, typical procedures for deliveries, sanitation.


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