COVID-19 Release

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To prevent the spread of COVID-19 and reduce the potential risk of exposure we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.
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In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:
I do not, nor do any member(s) of my household have pending COVID-19 test results.
I have not been, nor any member(s) of my household, have tested positive with COVID-19 within the last 30 days.
I did not, nor any member(s) of my household, visit any any area within the United States that was reported to be highly affected by COVID-19, in the last 30 days .
I have not experienced chills, loss of sense of taste /smell or a cough within the last 14 days.
I confirm that if I present symptoms between now and my appointment that I willcancel. I also understand that I can be denied services if I show up with symptoms.
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Following the pronouncements above I hereby declare the following:
Due to its capacity to transmit from person-to-person through respiratory droplets, and the inability of people to social distance when receiving services there is a hightened risk of contracting the virus.
With full knowledge of the risks involved, I hereby release, waive, discharge the Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.
I agree to indemnify, defend, and hold harmless the Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.
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By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.
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Name
First Name
Last Name
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Phone Number
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Signature
Clear
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Date Signed
Date
Month
Day
Year
Should be Empty: