I {participantName} have chosen to attend the Academy for Injection Anatomy course in facial injection (the “Course”) to be presented by Christopher C. Surek, D.O and Surek, LLC (collectively, ”Surek”).
I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact, and, as a result, federal and state health agencies recommend social distancing. I recognize that Surek has put in place reasonable preventative measures aimed to reduce the risk of Course attendees becoming infected with COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of attending the Course. I hereby acknowledge and assume the risk of becoming infected with COVID-19 by attending the Course.
I understand that, even if I have been tested for COVID-19 and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID-19 after the test.
I understand that possible exposure to COVID-19 from attending the Course may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death.
I understand that COVID-19 may cause additional risks, some or many of which may not be known at this time, in addition to the risks described herein.
I understand all the potential risks, including, but not limited to, the potential short-term and long-term complications related to COVID-19, and I would like to attend the Course.
By signing this form, I voluntarily assume the risk that I may be exposed to or infected with COVID-19 by attending the Course. I understand that the risk of becoming infected with COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Surek agents and other Course attendees.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, illness, disability, death, or damages or loss of any kind), that I may experience or incur in connection with my attendance at or participation in the Course (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless Surek, their employees, agents, and representatives, of and from any Claims, including all liabilities, claims, actions, damages, costs and expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Surek and their employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after attending the Course.
I ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND AM FULLY AWARE OF THE LEGAL CONSEQUENCES OF SIGNING THIS INSTRUMENT.