Release of Liability COVID-19

Confirmation of School Relationship*

I'm an adult student
I'm a legal guardian of an enrolled student(s) or activity participant(s)

Name of Legal Guardian No. 1 of Student(s); or name if adult student.*

First Last

Name of Legal Guardian No. 2 of Student(s) (If Any)

First Last

Transportation 1*

Name of Person most frequently providing transportation, if/when in-person

First Last

Relationship of Transporter 1 to student*

Mother
Father
Grandparent
Myself -I'm the student
Other relative
Other

Transportation 2

Name, if any, of 2nd family member who may, at any time, be providing transportation if/when visiting in-person.

First Last

Relationship of Transporter 2, if any

Mother
Father
Grandparent
Other relative
Other
None - Transporter No. 1 is the only person who will ever visit in-person.

Additional Contact Information

If anyone other than yourself, Legal Guardian 1 and/or 2 will or might provide transportation, please provide name and email here.

Assumption of Risk / Waiver of Liability

We are unable to allow anyone to visit the school, nor any of its satellites, nor partake in any in-person school activity unless you have submitted a signed copy of this waiver in advance of your visiting or participating in any school activity.

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing, the use of masks, and have, in many locations, prohibited the congregation of groups of people.

Pakachoag Music School (the “School”) has put in place preventative measures to reduce the spread of COVID-19; however, the School cannot guarantee that you or a family member will not become infected with COVID-19. Further, visiting the School in-person could increase your risk and your child(ren)’s risk of contracting COVID-19.

Please read and sign below acknowledging that you assume all risk as follows.

By signing this agreement, 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 the School and that such exposure or infection may result in personal injury, illness, permanent disability, and / or death.

I understand that I, as adult student or legal guardian, or my designated transportation provider, may not visit the School or any of its satellite locations with any additional guest(s).

I understand that the risk of becoming exposed to or infected by COVID-19 at the School may result from the actions, omissions, or negligence of myself and others, including, but not limited to, School 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 School programming (“Claims”).

On my behalf, and on behalf of my family members, I hereby release, covenant not to sue, discharge, and hold harmless the School, 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 the School, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after visiting or participating in any School program.

Consent / Legal Guardian Signature*

I confirm that by entering my name here, that I, on behalf of myself and my family members, including my child or children, accept the conditions of the above assumption of risk and liability relating to COVID-19; and that my entry of name serves as my legal signature.

Consent - Adult Student*

I confirm that by entering my name here, I on behalf of myself and my family members, accept the conditions of the above assumption of risk and liability relating to COVID-19; and that my entry of name serves as my legal signature.

Consent / Legal Guardian Signature*

I confirm that by entering my name here I have received and read a copy of the COVID-19 Safety Guidelines Handbook dated August 13, 2020. I agree that I have shared or will share the handbook with any other family member who may be participating in school activities. I and any members of my family engaged in school activities will adhere to the guidelines outlined to the full extent possible.

Today's Date*

Phone

This field is for validation purposes and should be left unchanged.

COVID-19 Release of Liability-Families & Adult Students

Assumption of Risk / Waiver of Liability

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