COVID-19 - School Activities Student Permission Form, Release and Hold Harmless

In consideration of _________________________________ (NAME OF STUDENT)(hereinafter “Student”) being allowed to attend and participate in-person in Waukesha North (hereinafter “School”) school related activities (hereinafter “Activities”), to include but not limited to educational, co-curricular, and extracurricular programs, the undersigned acknowledges and agrees that:

1. The risk to have contact with individuals, who have been exposed to and/or have been diagnosed with one or more communicable diseases, including but not limited to coronavirus disease 2019 (hereinafter “COVID-19”) or other medical conditions, diseases, or maladies does exist, and, despite School’s good faith implementation of the Wisconsin Department of Instruction’s recommended health, hygiene, and social distancing best practices, it is impossible to eliminate the risk that Student might be exposed to and/or become infected through contact with or close proximity with an individual with a communicable disease. Risk from contracting such communicable disease might include, illness, permanent disability, or death.

2. COVID-19 is a new disease and there is limited information regarding risk factors for severe disease. Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions might be at higher risk for severe illness from COVID-19.
Based on Center for Disease Control (hereinafter “CDC”) guidance, those at high-risk for severe illness from COVID-19 are: people 65 years and older; people who live in a nursing home or long-term facility.
Those at severe risk also include people of all ages with underlying medical conditions, particularly if not well controlled, including, but not limited to: chronic lung disease or moderate to severe asthma; serious heart conditions; those who are immunocompromised (many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications); severe obesity (body mass index [BMI] of 40 or higher); diabetes; chronic kidney disease undergoing dialysis; and, liver disease.
3. By signing below the undersigned acknowledges that Student does not have an underlying medical condition, as referenced herein, or that if Student has such underlying medical condition that the undersigned will first obtain written permission from a licensed healthcare professional prior to Student attending or participating in School Activities, which written approval will be provided to School in advance of attendance or participation.
4. People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19: cough; shortness of breath or difficulty breathing; fever of 100.3 degrees Fahrenheit or above; chills; muscle pain; sore throat; new loss of taste or smell. This list is not all possible symptoms. Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea.
5. Student will not attend School Activities and Student or Student’s parent or guardian will notify School officials if Student currently has symptoms or have been in contact with anyone with a confirmed COVID-19 diagnosis in the last 14 days.

6. If Student has been diagnosed with COVID-19. Student will not attend or participate in School Activities until they have received written medical approval from a licensed health care professional, which approval will be provided to School prior to Student’s attendance.

7. Student will not attend or participate in School Activities if they are subject to state or federal government directed quarantine or isolation.

8. School retains the right to deny Student’s attendance or participation in School Activities, if School determines that such attendance or participation is an undue health risk to Student or others. School similarly has the right to deny any other individual from attending School Activities if said individual’s attendance poses an undue health risk to that individual or others.

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9. THE UNDERSIGNED KNOWINGLY AND FREELY ASSUMES ALL SUCH RISKS for Student’s attendance or participation in School Activities.

10. The undersigned agrees that the undersigned and Student will comply with any safety or health related rules, terms, or conditions for participation in School Activities.

11. If Student or Student’s parent or legal guardian observe any unusual, significant hazard during their presence or participation in School Activities, Student or Student’s parent or guardian will remove Student from participation and bring such observation to the attention of the nearest School employee.

After fully and carefully considering all the potential risks involved, I hereby assume the same and agree to release and hold-harmless The School District of Waukesha and its employees, officers, agents, contractors and vendors (“School”) from and against, all claims and liability resulting from exposure to disease-causing organisms and objects, such as COVID-19, associated with Student participating in School Activities, to include, but not limited to educational, co-curricular, or extracurricular programs.