MCDC COVID-19 WAIVER FORM
Risk Assessment and Waiver of Liability
This form is solely for the purpose of screening all individuals during the COVID-19 pandemic for the protection of staff and clients.This waiver will serve as acknowledgment of this and any future visit. If your situation should change, please notify the staff at MCDC or myself (917) 831-8035 Miss Cheryl.
**Please read the following statements and terms before registering your child. By clicking accept at the end of this waiver means you give consent.
1. I am aware that COVID-19 has a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it.
2. I understand that anytime I am within close proximity (less than 6ft) of my service provider or any other person, I could have an elevated risk of contracting the virus should it be present.
3. I confirm that none of the following COVID-19 symptoms have been present within the last 2-14 days: Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Muscle Pain or Headache.
4. I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days inside or outside of the country I reside in.
5. I affirm that I have not traveled domestically (outside of my state) or internationally (outside of my country) within the past 14 days.
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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, including individuals without disease symptoms. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited or limited the congregation of groups of people.
The health and well-being of our staff and students remains our top priority. In order to minimize the risk of COVID-19 entering MCDC environment and spreading amongst our community, we will only allow staff assigned to work and students scheduled to participate to be in MCDC studio. Parents wishing to remain on site will have to wait outside or in the car for their child(ren). Students waiting to attend a session will need to wait in the waiting room while maintaining social distance from others.
Furthermore, all participants MCDC must agree to and abide by the following:
â— MAINTAIN SOCIAL DISTANCING (6FT) AT ALL TIMES
â— IF YOU ARE FEELING ILL, PLEASE REFRAIN FROM ENTERING THE FACILITY
â— SANITIZE OFTEN, WASH HANDS FREQUENTLY
â— MASKS ARE RECOMMENDED, BUT NOT REQUIRED
MCDC-MISS CHERYLS DANCE COMPANY
has put in place numerous preventative measures and enhanced cleaning protocols to reduce the likelihood of spreading COVID-19; however, MCDC cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending MCDC could increase your risk and your child(ren)’s risk of contracting COVID-19.
By accepting this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily agree to the participation terms described above and assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending MCDC 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 at MCDC may result from the actions, omissions, or negligence of myself and others, including, but not limited to, MCDC 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 my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage and loss.
On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless MCDC and it’s employees.
I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of MCDC, its employees and representatives, whether a COVID-19 infection occurs before, during, or after participation in any MCDC activity.
ONCE YOU ACCEPT THIS WAIVER, YOU GIVE CONSENT
FOR YOU AND YOUR CHILD.