Covid-19 Waiver

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important and required to help us take precautionary measures to protect you and everyone in this building. Thank you for your time, consideration, and truthful responses.

You agree to reschedule if you cared for someone diagnosed with COVID-19 within the 14 days of the appointment.

You agree to reschedule if you experienced any cold or flu-like symptoms within 14 days of the appointment

You agree to wear a mask at the time of your appointment.

By signing this agreement, 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 my mere presence within this establishment and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, and program participants and their families. I hereby release the booked business from any and all claims arising from or in connection with any direct COVID-19 impact while visiting.

I HAVE READ AND UNDERSTOOD THIS DOCUMENT AND I AGREE TO BE BOUND BY ITS TERMS. *

First Name

Last Name

Today's Date

Your Signature