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    Health Declaration and Waiver Form

    Uploaded by

    boomblebee
    This document is a health declaration and waiver form for a church to help prevent the spread of COVID-19. It lists common symptoms of COVID-19 like fever and cough. Members must sign agreeing that they do not have symptoms, have not been diagnosed with COVID-19, or been exposed to it. They also agree not to have traveled to hot spots. The church will do temperature checks, require masks, practice social distancing and limit capacity to prevent spread of the virus. By signing, members waive liability for any exposure to COVID-19 at the church.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Health Declaration and Waiver Form

    Uploaded by

    boomblebee
    129 views1 page
    This document is a health declaration and waiver form for a church to help prevent the spread of COVID-19. It lists common symptoms of COVID-19 like fever and cough. Members must sign agreeing that they do not have symptoms, have not been diagnosed with COVID-19, or been exposed to it. They also agree not to have traveled to hot spots. The church will do temperature checks, require masks, practice social distancing and limit capacity to prevent spread of the virus. By signing, members waive liability for any exposure to COVID-19 at the church.

    Original Title

    Covid Waiver

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    This document is a health declaration and waiver form for a church to help prevent the spread of COVID-19. It lists common symptoms of COVID-19 like fever and cough. Members must sign agreeing that they do not have symptoms, have not been diagnosed with COVID-19, or been exposed to it. They also agree not to have traveled to hot spots. The church will do temperature checks, require masks, practice social distancing and limit capacity to prevent spread of the virus. By signing, members waive liability for any exposure to COVID-19 at the church.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    129 views1 page

    Health Declaration and Waiver Form

    Uploaded by

    boomblebee
    This document is a health declaration and waiver form for a church to help prevent the spread of COVID-19. It lists common symptoms of COVID-19 like fever and cough. Members must sign agreeing that they do not have symptoms, have not been diagnosed with COVID-19, or been exposed to it. They also agree not to have traveled to hot spots. The church will do temperature checks, require masks, practice social distancing and limit capacity to prevent spread of the virus. By signing, members waive liability for any exposure to COVID-19 at the church.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    HEALTH DECLARATION AND WAIVER FORM

    Due to the outbreak of the novel Coronavirus (COVID-19), our church is taking
    extra precautions with the care of every member to include health history
    review and enhanced sanitation/disinfecting procedures in compliance with
    IATF guidelines.

    Symptoms of COVID-19 include:


    • Fever
    • Fatigue
    • Dry Cough
    • Difficulty in Breathing

    By placing member’s signature at the bottom of this page, he/she hereby


    agrees/declares the following:
    • I understand the above symptoms and affirm that I, as well as all household
    members, do not currently have, nor have experienced the symptoms listed
    above within the last 14 days.
    • I affirm that I, as well as all household members, have not been diagnosed
    with COVID-19 within the past 30 days.
    • I affirm that I, as well as all household members, have not knowingly been
    exposed to anyone diagnosed with COVID-19 within the past 30 days.
    • I affirm that I, as well as all household members, have not travelled outside of
    the country or to any city considered to be a “hot spot” for COVID-19 infections
    within the past 30-days.
    • I understand that _________________, Inc. cannot be held liable for any
    exposure to the COVID-19 virus caused by misinformation on this form or the
    health history provided by each church member.

    Our church is following theses enhanced procedures to prevent the spread of


    COVID-19:
     No mask/No entry
     Hand and Foot sanitation
     Temperature check
     One-meter social distanced seating arrangement
     50% venue capacity pursuant to MGCQ guidelines

    By signing below, I agree to each statement above and release


    _______________________ Inc. from any and all liability for unintentional
    exposure or harm due to COVID-19.

    ____________________________
    Signature over printed name

    _______________
    Date

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