Covid-19 Waiver

I’m agreeing to participate in a Backyard Bookworm class and agree to the following: COVID-19 Risk Exposure: I acknowledge that the CDC, the State of New York and other public health authorities have confirmed the contagious nature of COVID-19 and that there is an inherent danger and risk of exposure to COVID-19 in any place where people are present. Therefore, I agree to: 

I, the parent or guardian, will bring my own blanket or towel for the participant child and myself, and will keep it 6 feet apart from others. 

Although all precautions will be taken, I understand that “The Happy Bookworm, Inc” can not guarantee that the parent/guardian nor the participant child will not become infected with COVID-19. Additionally, “The Happy Bookworm, Inc” is not responsible for any illness or injury during or after the class . 

By signing this I am agreeing not to attend class if any of the following apply: 

• I or the participant child for whom I am responsible for, are experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat, or new loss of taste or smell. 

• Neither I nor the participant child for whom I am responsible have traveled internationally or to any state that is currently on the New York State quarantine list within the United States of America within the last 14 days. 

• I do not believe and have no knowledge that I or the participant child for whom I am responsible have been exposed to someone with a suspected or confirmed case of COVID-19 in the last 14 days.

• Neither I nor the participant child for whom I am responsible have been diagnosed with COVID-19 or have been subject to a state or health authority order of quarantine or isolation as a result of potential exposure to COVID-19 in the last 14 days. 

Participant Child’s Name_________________________________________________________ 

Parent/Guardian Name (print) ___________________________________________________ 

Home Address ___________________________________________________________________ 

Cell phone number ______________________________________________________________

Parent/Guardian Signature ______________________________________________________ 

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Please check one of the following: I give permission for my child’s photo to be used for marketing purposes. 

I do_____ OR I do not______