2024 Health Liability Release Waiver

Due to (but not limited to Influenza, RSV and other communicable disease capacity to transmit from person-to-person through respiratory droplets, the government does on occasion set recommendations, guidelines, and some prohibitions which Clallam Mosaic complies with.

Name of Participant*

First NameLast Name

When I participate in Clallam Mosaic in-person activities, I agree to the following:

I am aware of the existence of the risk with my participation in Clallam Mosaic activities.Despite all possible preventative measures, my participation may cause injury or illness such as, but not limited to Influenza, MRSA, or any other communicable disease.I am aware that certain participants in Clallam Mosaic's activities travel to and from programs on Clallam Transit. I also understand that there is inherent risk of exposure through individuals riding to Mosaic programs on Clallam Transit.I will not attend Mosaic programs if I have experienced symptoms of flu, fever (a temperature of 99.5 or above), difficulty in breathing, cough, vomiting or exhibited any other symptoms relating to Influenza, or RSV or any communicable disease within 3 days of my attendance date.I will not attend Mosaic programs if I, or any member(s) of my household, have been diagnosed to be infected with any other infectious disease within 3 days of my attendance date.

I agree to the following:

I am fully and personally responsible for my own safety and actions during participation in Clallam Mosaic activities.With full knowledge of the risks involved, I hereby release Clallam Mosaic, its Board, volunteers and employees, from any and all liabilities directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to Influenza, RSV or any communicable disease while participating in any Clallam Mosaic activity that may lead to unintentional exposure or harm due to Influenza, RSV or any communicable disease.I agree to indemnify, defend, and hold harmless Clallam Mosaic 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 parties due to injury, loss, or death from or related to Influenza, RSV or any communicable disease.

Please complete the appropriate release section (Participant or Authorized Representative) below and sign.

PARTICIPANT Signature:

By signing below, I acknowledge that I have read Clallam Mosaic's 2025 Health 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 with full intention to be bound by the same, and free from any inducement or representation.

Name of Participant that will sign this form

First NameLast Name

AUTHORIZED REPRESENTATIVE Signature:

By signing below, I acknowledge that I have read Clallam Mosaic's 2025 Health 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 with full intention to be bound by the same, and free from any inducement or representation.

Name of Authorized Representative that will sign this form

First NameLast Name

Phone Number of Signer

Email address of Authorized Representative

example@example.com

Signature

Date Signed

Date

To complete registration, the following forms are needed:

Fill out once for 2025:

2025 In-Person Intake Form
2025 Health Status Form
2025 Health Liability Release Waiver
2025 In-Person Code of Conduct
2025 Participant Consent Form

Filled out each Term:

The appropriate term's Registration Form

Clallam Mosaic Health Liability Release Waiver