JCUMC COVID-19 Liability Waiver

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All persons desiring to attend in person worship at Jackson Chapel UMC will be required to sign a liability waiver BEFORE entering the building.

Your full name: *

Name of Family Members: (give ages for under 18) *

I agree to the following: *

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the U.S. Centers for Disease Control ("CDC") and many other public health authorities still recommend practicing social distancing and wearing masks in public locations.

I voluntarily seek in-person worship provided by Jackson Chapel United Methodist Church "JUMC" and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending on-site activities.

I further acknowledge that JCUMC cannot guarantee that I will not become infected with the Coronavirus/COVID-19 while attending any services or functions at the Church.

I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from an Act of God or other unknown cause or also the actions, omissions, or negligence of myself and others, including, but not limited to JCUMC staff, and other members and their families.

Required

I attest that: *

I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell

I have not traveled internationally within the last 14 days.

I have not traveled to a highly impacted area within the United States of America in the last 14 days.

I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.

I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.

I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

Required

In regards to the COVID-19 Vaccination:

I have received my first shot of the vaccine

I have been fully vaccinated

I have not received the vaccine

I prefer not to respond

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In the event of need to contact you, please leave a phone number that we can use to best contact you:

I hereby release and agree to hold JCUMC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the church, or that may otherwise arise in any way in connection with any services received from JCUMC. I understand that this release discharges JCUMC from any liability or claim that I, my heirs, or any personal representatives may have against JCUMC with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from JCUMC. By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing statement. Please signify your acceptance by entering your full name below. *

Date of signature *

YYYY

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