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Home » COVID-19 Forms » Waiver and Release of Liability Form

Waiver and Release of Liability Form

  • Acknowledgement and Assumption of Risk

  • Company has taken all precautions recommended by the Centers for Disease Control and Prevention for business who are continuing to provide services to customers during the COVID-19 crisis. This includes the the Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19) and Cleaning and Disinfecting Facilities. Additionally, Company has been screening our employees before every work shift to ensure that no employee is suffering any of the known symptoms of COVID-19, including running a fever, having a dry cough, or experiencing shortness of breath. However, it is also known that those without symptoms may still be capable of infecting others as an asymptomatic individual with COVID-19 and despite precautions taken the virus may still be present and capable of infecting individuals.

    Knowing this information, I voluntarily elect to continue with my scheduled appointment with Company and I hereby agree to accept and assume any and all risks of personal injury or death.

    Waiver of Liability and Indemnification
    In consideration for being treated by Company, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever:
      a. waive, release, and discharge Company, its agencies, officers, and employees from any and all negligence and liability for my death, disability, personal injury, or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced appointment; and

      b. defend, indemnify, and hold harmless Company, its agencies, officers and employees, from any and all claims of any nature, including all costs, expenses, and attorney's fees, which may in any manner result from or arise out of this agreement, except for claims resulting from or arising out of Company willful or intentional negligence.
    This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.
  • I, the undersigned, affirm that I am at least 18 years of age and am freely signing this agreement or that I am signing on behalf of a minor child that I have the legal authority to sign such agreements on behalf of. . I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my appointment. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.

    Read Before Signing

  • Date Format: MM slash DD slash YYYY

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