Health and Safety PledgeSummer 2021 To keep our community healthy and safe, we require all students, student families/caregivers, faculty, staff, and individuals entering the building to read and sign this pledge for summer 2021. Families with multiple students can complete one form. Question Title * 1. Please let us know your relation to the Music School Student or Student Family Faculty Staff Visitor Other (please specify) Question Title * 2. Student/Faculty/Staff/Visitor Name(s) (Please list all students if multiple family members are enrolled) Question Title * 3. Parent/Guardian Name (if under 18) Question Title * 4. Please list your contact information Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Country Email Address * Phone Number * Concord Community Music School (henceforth referred to as “CCMS”) has put in place preventative measures to reduce the spread of COVID-19; however, CCMS cannot guarantee that you or a family member will not become infected with COVID-19. Further, visiting CCMS in person could increase your risk and your child(ren)’s risk of contracting COVID-19, as there is increased risk in a Music School setting which involves singing and wind instruments. Question Title * 5. Please read each statement carefully and initial each statement before signing the bottom of this form. I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I and my family members may be exposed to or infected by COVID-19 by visiting CCMS and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I agree to wear a mask covering my nose and mouth when entering the CCMS building. Masks are required for individuals over the age of 2, per CDC guidelines. I agree that I will stay home if I am not feeling well. I will not come to CCMS if I or anyone in my household has experienced any COVID-19 symptoms in the last 72 hours. If I or anyone in my household tests positive for COVID-19, and I have been in CCMS in the last 14 days, I will notify the Director of Administration. If there is an active diagnosed COVID-19 case with whom I am in regular contact, or if I have been exposed to a diagnosed individual within the last 14 days, I will not enter CCMS. I understand that the risk of becoming exposed to or infected by COVID-19 at CCMS may result from the actions, omissions, or negligence of myself and others, including, but not limited to, CCMS employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself and my family members (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my or my family's participation in CCMS programming (“Claims”). On my behalf, and on behalf of my family members, I hereby release, covenant not to sue, discharge, and hold harmless CCMS, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of CCMS, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after visiting or participating in any CCMS program. By signing below, I am indicating that I have read and understand Concord Community Music School’s health and safety policies as outlined in the safety protocols document for summer 2021. Question Title * 6. Signature Done
