Conceptual Fade Covid -19 Release Waiver

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Must be filled out before visit.

Email *

Full Name *

Email Address *

Todays Date *

YYYY

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that TNM Studios, LLC / Conceptual Fade has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. *

Yes

I further acknowledge that TNM Studios, LLC / Conceptual Fade can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other vsitors and their families. I voluntarily seek services provided by TNM Studios, LLC / Conceptual Fade and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19 *

Yes

I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. *

Yes

I attest that: * I am not experiencing any symptom 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. *

Yes

I attest that: * I have not traveled internationally within the last 14 days. *

Yes

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

Yes

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

Yes

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

Yes

* I hereby release and agree to hold TNM Studios, LLC / Conceptual Fade 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 library/gallery, or that may otherwise arise in any way in connection with any services received from TNM Studios, LLC / Conceptual Fade. *

Yes

I understand that this release discharges TNM Studios, LLC / Conceptual Fade from any liability or claim that I, my heirs, or any personal representatives may have against the library/gallery 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 TNM Studios, LLC / Conceptual Fade. This liability waiver and release extends to the library/gallery together with all owners, partners, and employees. *

Yes

Signature - Please type full Name *

A copy of your responses will be emailed to the address you provided.

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