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COVID-19 / ADVERSE REACTION WAIVER
Crystal Drake, LLC
190 N. Main St., Plymouth, MI 48170

HEALTH SCREENING, ASSUMPTION OF RISK AND WAIVER OF LIABILITY

Crystal Drake LLC (“Drake”) seeks to put our clients’ health first and foremost.  We have put in place preventative measures to reduce the spread of communicable diseases, including COVID-19 as required under Federal and Michigan law, however, Drake cannot guarantee that you will not become infected with a communicable disease, including COVID-19, as a result of Drake’s services.  Drake will also do its best to prevent any adverse reaction to the products it uses, however, Drake cannot guarantee that you will not suffer an adverse reaction.  

SAFETY PROTOCOLS

Communicable Diseases:

The State of Michigan requires the following for personal care services to be performed during the COVID-19 epidemic.  The Company and its artists follow and enforce these protocols to protect clients and artists:

  • Clients must wear a face covering when not actively receiving a service that requires the client to remove the face covering. 
  • Artists will always wear a face covering and when the client cannot wear a face covering, the artist will also wear a face shield or goggles.
  • Clients/artist stations will be spaced 6ft from each other
  • Only artists and clients who are being actively serviced will be permitted in the service room. 
  • Standard industry protocols as defined in Mich Admin Rules 338.2179a (basic sanitation protocols)
  • All surfaces disinfected regularly throughout the service and between clients
  • Artists will follow CDC Handwashing guidelines between clients and throughout each client’s service.
  • All tools (including brushes) are double-washed and disinfected between clients.  Soiled brushed are segregated from clean brushes in a sealed container.

Allergies:

The Company will make reasonable efforts to eliminate Client’s exposure to any explicitly stated allergens; however, Client acknowledges that:

  • the Company may refuse to perform services for Client if the Artist, based on their knowledge of the products in their kit, how they are stored, and their ingredients, deems the service to be a danger to the client.  In this instance, a refund for the services the Company refused will be issued.
  • the Artist's cosmetic products are all housed together in one case and cross-contamination may be unavoidable, depending on the allergen or sensitivity.
  • the Artist may not have an alternative product that does not contain the allergen.
  • for on-location services, there may be circumstances or elements of the service environment that the Company cannot control. 
  • Client may provide their own new and unopened cosmetics for the Company to use during their services, should Client prefer.  Products must be new and sealed.  

All clients are required to complete the following health screening, and sign the following assumption of risk and waiver of liability:

HEALTH SCREENING

GENERAL HEALTH SCREENING (please initial in the boxes provided):

By signing this agreement, I affirm that I have disclosed all allergies, skin conditions, and medications and/or medical or skincare treatments to Drake that may cause me to have an adverse reaction to the makeup and/or skincare products that are applied by Drake in conjunction with their services. 



I acknowledge that there is always a possibility of an unforeseen reaction to any of the products used by Drake in conjunction with its services and that such reaction may result in personal injury, illness, permanent disability, and death.


I affirm that I have not had symptoms or a confirmed diagnosis of the following WITHIN THE PAST 14 DAYS:

  • Influenza (flu)
  • Conjunctivitis (pink eye)
  • Herpes labialis (cold sore)
  • Head lice
  • Scabies
  • Impetigo



I acknowledge that if I fail to disclose any of the following health conditions and they are discovered during my service, Drake reserves the right to immediately cancel my service and will not refund my payment.

COVID-19 HEALTH SCREENING (please initial in the boxes provided):

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. 

Symptoms of COVID-19 include:

  • Fever
  • Fatigue
  • Dry Cough
  • Difficulty Breathing
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

I understand the above symptoms and I affirm that I, as well as all household members, do not currently have, nor have experienced any of the symptoms listed above WITHIN THE LAST 14 DAYS.



I affirm that I, as well as all household members, have not been diagnosed with COVID-19 WITHIN THE LAST 30 DAYS.

 
I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 WITHIN THE PAST 30 DAYS

 
I affirm that I, as well as all household members, have not traveled outside of the country, or to any city considered to be a "hot spot" for COVID-19 infections WITHIN THE PAST 30 DAYS.

 
I understand that Drake cannot be held liable for any exposure to the COVID-19 virus or any other contagion caused by misinformation on this form or the health history provided by each client.

 
I understand that I will have to remove my mask in order to receive Drake’s makeup services, and that this may increase the likelihood of my exposure to the virus.


 

ASSUMPTION OF RISK AND WAIVER OF LIABILITY

By signing this agreement, I agree to each statement in the health screening above and I acknowledge the contagious nature of communicable diseases, including COVID-19 and voluntarily assume the risk that I may be exposed to or infected by communicable diseases, including COVID-19, by receiving services from Drake 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 communicable diseases, including COVID-19, may result from the actions, omissions, or negligence of myself and others, including, but not limited to Drake employees and other clients.  I also voluntarily assume the risk that, despite Drake’s best efforts to avoid it, I may have an adverse reaction caused by any disclosed, undisclosed, or unknown allergies, skin condition, or other medical condition.  

I voluntarily agree to assume all known and unknown risks arising out of Drake’s services 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 the services I receive from Drake (“Claims”). I hereby release, covenant not to sue, discharge, and hold harmless Drake, its employees, agents, and representatives, 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 Drake, its employees, agents, and representatives, whether the injury, communicable disease infection, including a COVID-19 infection, or adverse reaction occurs before, during, or after I receive Drake’s services.

I further acknowledge that if I knowingly provide false information on this form, and a Drake employee or contractor becomes ill as a result, I will be held legally responsible to the extent allowed under Michigan law.  

I have read and understand the terms of this Health Screening, Assumption of Risk and Waiver of Liability and agree to its terms:

First Clients Name

First Name*

Last Name*

Phone*
First Clients Age Acknowledgment*
First Clients Date of Birth*
I certify that I am 18 years of age or older
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
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*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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