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Please read this fully. If there is any part that is unclear, please ask for assistance. DO NOT SIGN if there is any part that is unclear. By signing you signify that you understand fully.

2020 COVID-19 Pandemic Waiver and Consent Form

I knowingly and willingly consent to services at the The Cryotherapy Place on behalf of Patient/Myself during the COVID-19 pandemic. 

I Agree

 I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

 I understand that while The Cryotherapy Place LLC, dba CryoPlace, has procedures in place in line with WHO and the CDC, there has not been any promise of a COVID free environment. And knowingly and willingly accept responsiblity for inherit risk of receiving services during the COVID-19 pandemic.

I understand I should wear a protective mask over my mouth to prevent infection during participation. However, I may still be vulnerable to COVID-19 transmission while participating in services at the The Cryotherapy Place.

 I understand that due to the visits of members and participants, the characteristics of the virus, and the characteristics of this activity, that I may have an elevated risk to exposure.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID.19. I have disclosed any condition that compromises my immune system and understand that I may be asked toconsider rescheduling this activity after discussing any such conditions with the The Cryotherapy Place staff.

DISCLOSURE:

It is also important that you disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

 I attest that I do not have a fever or above normal temperature.

I attest that I am not experiencing shortness of breath or had trouble breathing.

 I do not have a dry cough?

 I do not have a runny nose?

I have not tested positive for COVID -19 nor been knowingly exposed to anyone that has tested postiive.

I have not recently lost or had a reduction in my sense of smell

I do not have a sore throat?

I am not awaiting results to COVID-19 test results.

I have not traveled outside the United States by air or cruise ship in the past 14 days.

I have not traveled within the United States by air, bus or train within the past 14 days.

By signing below in both my individual capacity and as Parent/Guardian, if applicable, I represent that I have fully read and understood the provisions above, have had the opportunity to ask questions about any of the above, and that I accept the associated risk to myself and to minor

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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