I have been given a copy of the Fact Sheet for Recipients and Caregivers for the Emergency Use Authorization (EUA) of the Moderna COVID-19 vaccine and have read it.  I have had the chance to ask questions and I am satisfied with the answers and explanations given. I understand that this vaccine has not yet been approved by the Food and Drug Administration (“FDA”), and is being given under an FDA issued EUA. I understand the benefits and risks of this vaccine and ask that the vaccine be given to me, or the person for whom I am authorized to make this request. I understand that because this is not an FDA-approved vaccine but is being given under an FDA issued Emergency Use Authorization, the State of Hawaii, its departments, agencies and employees (“the State”) are immune from civil liability under federal and state law for all claims for loss related to any known or unknown side effects and/or injuries, including but not limited to death, that I, or the person for whom I am authorized to make this request, may experience from this vaccine. This immunity means that if I file a lawsuit against the State, the court must dismiss any such lawsuit, and the only exception to this immunity is for claims of willful misconduct. In addition, I have received information regarding the Hawaii Immunization