Covid Liability Waiver

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* 1. Full Name (first & last)

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* 2. What day will you or your child be on campus? (PLEASE MAKE SURE THIS FORM IS FILLED OUT NO MORE THAN 24 HOURS BEFORE YOU ARRIVE TO CAMPUS)

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* 3. What committee do you or your child belong to?

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* 4. Email Address

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* 5. Due to the novel Coronavirus (COVID-19) pandemic, AGBU Vatche & Tamar Manoukian Center is taking extra precautions with the care of every member and visitor to include a health history review and enhanced sanitation procedures. Symptoms of COVID-19 may include:

• 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

By initialing in each box, I agree to the following:

I will immediately notify the AGBU West Coast office if I have been exposed to COVID-19.

I understand the above symptoms and affirm that I, and my household members, do not have and am not experiencing the symptoms listed above within the last 14 days.

I affirm that I and those in my household have not been diagnosed with COVID-19 in the past 30 days.

I have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days.

I affirm that I have not traveled outside of the country within the past 30 days.

I understand that the Centers for Disease Control (CDC) has stated that there is evidence that persons with COVID-19 may be asymptomatic or pre-symptomatic, and that the virus may be transmitted to the patient or others by me if I am such a carrier.

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* 6. I understand that I am being allowed access to AGBU Vatche & Tamar Manoukian Center and that I must follow all visitation rules and requirements for my safety and that of others including but not limited to:

Wear a mask over my nose and mouth for the duration of my visit

Be mindful of social distancing keeping 6 feet away while in hallways/common areas, offices, gym area, Boyadjian Hall, parking area, and all outdoor designated meeting spaces.

Wash my hands with soap and water or alcohol-based hand sanitizer before entering and leaving the offices or gathering areas.

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* 7. I understand that despite adhering to all precautions, there is still a possibility that I will be exposed to or contract COVID-19. Persons with underlying health conditions may be particularly susceptible to illness and death from COVID-19. Such conditions include but are not limited to heart disease, chronic lung disease, suppressed immunity system, severe obesity, diabetes, chronic kidney disease and liver disease. I have been advised and choose to visit, understanding my own health condition(s).

I have read the above and understand it is not inclusive of all risks and safety measures related to COVID-19. I am choosing to visit AGBU Vatche & Tamar Manoukian Center during the pandemic. In accordance with applicable law and facility policy, I agree to enter into this wavier and release of liability.

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* 8. Please enter the date of the signed consent form

Date / Time

Date

Time

AM/PM

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* 9. Signature

Electronic signature; first & last name
Example: Jane Doe

**By signing this agreement, I waive and release AGBU Vatche & Tamar Manoukian Center its officers, directors, owners, subsidiaries, employees, contractors, agents, affiliates, attorneys, insurers, successors, and assigns from any and all liability to me, including liability to my personal representatives, assigns, heirs, and next of kin, for any loss, costs, claims, demands, causes of action, damages or suits at law and equity of any kind, including but not limited to claims for personal injury whether caused by negligence or otherwise, medical expenses, loss of services or wrongful death on account of, or in any way related to or arising out of my contracting COVID-19.

I have read and voluntarily sign this agreement effective as of the date set forth below.