Beloved Retreat COVID -19 Screening Questions & Waiver

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Please review the screening questions and check the box of the COVID-19 waiver in order to attend the Beloved Retreat on February 19, 2022. Thank you for your cooperation as we follow the guidelines given to us. Each person attending will need to complete the COVID-19 Waiver. All those attending the retreat will need to have a parent and/or guardian complete the Waiver.

On this form, by initialing each statement (checking the boxes), typing my name, and providing a date, I agree that this is my legal signature as the Guardian of the Retreatant. *

I agree.

Required

Guardian LAST NAME *

Guardian FIRST NAME *

Guardian Phone Number *

Guardian Contact Email Address *

Retreatant's LAST NAME *

Retreatant's FIRST NAME *

Retreatant's Year in High School *

Freshman

Sophomore

Junior

Senior

Screening and Self-Practices Relating to Coronavirus/COVID-19 *

The Retreatant has not had symptoms of COVID-19 within the last two weeks, and I agree to monitor the Retreatant for symptoms of COVID-19, including: fever of 100.4 or higher, cough, chills, sore throat, shortness of breath, unexplained fatigue, loss of taste or smell, unexplained body aches, nausea or vomiting.

The Retreatant has not been diagnosed with COVID-19 within the last two weeks, nor has she had close contact with anyone who has been diagnosed with or who may have symptoms associated with COVID-19 within the last two weeks.

During this retreat, the Retreatant agrees to wash her hands often, and for at least 20 seconds at a time, avoid touching her face, practice social distancing by staying at least 6 feet away from other people, cover her coughs and sneezes with the sleeve of her shirt or coat, and wear a face covering during the retreat.

Required

Assumption of Risk and Waiver of Liability Relating to COVID-19

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. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. The Office of Vocations - Beloved Retreat has put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you will not become infected with COVID-19. Further, participation in on-site meetings could increase your child(ren)’s or your risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by participating in on-site meetings at the Office of Vocations - Beloved Retreat 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 the Office of Vocations - Beloved Retreat may result from the actions, omissions, or negligence of myself and others, including, but not limited to, 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 myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my participation in on-site meetings at the Office of Vocations - Beloved Retreat (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless the Office of Vocations - Beloved Retreat and the Diocese of Orlando, and all of their current, former, and future agents, representatives, religious and employees and related entities (collectively, “the Diocese”) of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Diocese, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after or participation in on-site meetings. *

I agree to the Waiver of Liability due to COVID-19.

Required

Date *

YYYY

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