Scheck Family Religious School 2021-2022 COVID-19 Release Form

Waiver, Release & hold harmless

**Signature Required Prior to arrival**
Beth Torah Benny Rok Campus

and anyone else involved in the operations of Beth Torah Benny Rok Campus premises, including but not limited to, instructors, visiting faculty and staff (are hereinafter referred to as "Beth Torah Benny Rok Campus").
Age of Consent *

I am an Adult over the age of Eighteen (18). The Student is a Minor under the age of Eighteen (18).
What and With Whom are you learning? *

Scheck Family Religious School J2M B'nai Mitzvah Program
Minor Student's Name in Full

Given Name Family Name
COVID-19 Common Symptoms, as per WHO:

People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19:
- Fever or chills
- Cough
- Shortness of breath or difficulty breathing
- Fatigue
- Muscle or body aches
- Headache
- New loss of taste or smell
- Sore throat
- Congestion or runny nose
- Nausea or vomiting
- Diarrhea
- Dry Cough
- Tiredness
I agree to the following: *

I understand the aforementioned COVID-19 symptoms. I affirm that neither I, nor any member of my household, currently has or has experienced the aforementioned symptoms within the past 14 days. Furthermore, I will immediately inform the administration and discontinue classes if I, or any member of my household, develops any of the aforementioned symptoms. I affirm that neither I, nor any member of my household, has been diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform Scheck Family Religious School and discontinue classes if I, or any member of my household, is diagnosed with COVID-19. I affirm that neither I, nor any member of my household, has knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. Furthermore, I will immediately inform the administration and discontinue classes if I, or any member of my household, is knowingly exposed to anyone diagnosed with COVID-19. I affirm that neither I, nor any member of my household, has traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30 days. Furthermore, I will immediately inform the administration and discontinue classes once I, or any member of my household, returns from traveling outside of the country or to any city considered to be a "hot spot" for COVID-19 infections. I understand that Beth Torah Benny Rok Campus cannot be held liable for any exposure to the COVID-19 virus caused by any misinformation on this form or the health history provided by each Student. I confirm that I am the Parent or Legal Guardian of the Student
Beth Torah Benny Rok Campus will be adhering to the following enhanced procedures to prevent the spread of COVID-19.

Our staff will…
- Do a temperature check before entering the building, and ensure that it is below 100 degree
- Clean/Disinfect frequently touched surfaces thoroughly and at regular intervals.
- Wash/Sanitize our hands before and after each session.
- Wear our masks at all times.
- Maintain a safe distance at all times.
- Accommodate a limited number of students in each class to ensure physical distancing.
- Provide sanitizers in the reception area and other locations within the premises.
We are requesting that each of our students, please…
- Allow us to check their temperature before entering the premises to ensure it is below 100 degree.
- Wear a face mask at all times.
- Maintain a safe distance from others at all times.
- Use the hand sanitizer before entering and while exiting the building.
- Carry their own bottle or cup for drinking water.
In case a student presents any symptoms he or she will be taken to the nurse office, and parents will be notified immediately to pick him/ her up before the end session.

By signing below, I agree to each statement above and release Beth Torah Benny Rok Campus from any and all liability for the unintentional exposure or harm due to COVID-19.

Beth Torah Benny Rok Campus agrees to abide by these standards and affirms the same.
Student's Name in Full *

Given Name Family Name
Parent or Guardian's Name in Full

Given Name Family Name
Mobile Number *
Do not include "0" or "+91"
Email ID *

Confirmation Email example@example.com
Signature *

Please sign above Clear
Date

Day Month Year
Date of Submission
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Waiver, Release & hold harmless

Beth Torah Benny Rok Campus