Eyeland Lash | Client Intake Form

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people.

The applicant is fully aware of the current pandemic and the inherent risks involved. The customer is aware that the majority of serious cases and deaths contributing to this virus are in people over 60 years old.

Eyeland Lash (referred to here as “the Business”) has put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you will not become infected with COVID-19. Further, like any public place, it could increase your risk of contracting COVID-19.

Please initial each statement below and then sign the agreement in the end.

Initial *

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 visiting or coming on to the Business’ property and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death.

Initial *

I understand that the risk of becoming exposed to or infected by COVID-19 at the Business may result from the actions, omissions, or negligence of myself and others, including, but not limited to, the Business’ employees, volunteers, and program participants and their families.

Initial *

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself for (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance or presence at the Business or participation in the Business’ programming, events, or appointments (“Claims”).

Initial *

I hereby release, covenant not to sue, discharge, and hold harmless the Business, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.

Initial *

I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Business, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Business program, event, or appointment.

Full Name *

First Name Last Name

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Date

Assumption of Risk