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COVID-19 WAIVER, RELEASE, AND ASSUMPTION OF RISK FORM 
for Our Lady of Grace Church, Greensburg, PA
in the Diocese of Greensburg
1011 Mount Pleasant Road 
Greensburg, PA 15601
724-838-9480
Pastor:
Fr. Daniel L. Blout
Primary Parish Email: djapalucci@dioceseofgreensburg.org 

FORM MUST BE COMPLETED IN ALL RESPECTS,SIGNED, AND DATED TO AUTHORIZE THE WAIVER

The novel coronavirus, COVID-19, is a highly infectious, life-threatening disease declared by the World Health Organization to be a global pandemic. There is no current vaccine for COVID-19. COVID-19’s highly contagious nature means that contact with others, or with surfaces that have been exposed to the virus, can lead to infection. Additionally, individuals who may have been infected with COVID-19 may be asymptomatic for a period of time or may never become symptomatic at all. Because of its highly contagious and sometimes “hidden” nature, it is currently very difficult to control the spread of COVID- 19 or to determine whether, where, or how a specific individual may have been exposed to the disease.

I acknowledge the contagious nature of COVID-19, the fact that it can be difficult to identify in another person, and the inherent risks of exposure to those who may be infected with COVID-19. I voluntarily assume the risk that I/my child/my household members may be exposed to or infected by COVID-19 as a result of or in connection with my child’s attendance at school and that such exposure or infection may result in personal injury, illness, permanent disability, and/or even death.

I acknowledge that the CDC and many other public health authorities continue to recommend social distancing and other protective measures to prevent the spread of COVID-19, which may be updated at any time. I acknowledge that I/my child/my household members must comply with all set procedures to reduce the spread of COVID-19.

I understand that the PARISH AND DIOCESE OF GREENSBURG has put in place new rules and precautions in order to mitigate the spread of COVID-19, which may be updated at any time. While acknowledging that these rules and precautions may or may not be effective in mitigating the spread of COVID-19, I/my child/my household members agree to comply with such rules and precautions which may include, but are not limited to, wearing a face covering, hand washing, hand sanitizing, and social distancing.

I understand and acknowledge that given the unknown nature of COVID-19, it is not possible to fully list each and every individual risk of contracting COVID-19. I understand that the risk of I/my child/a household member becoming exposed to or infected by COVID-19 as a result of or in connection with my child’s attendance at school may result from the actions, omissions, or negligence of myself and others, including, but not limited to, priests; parish, or diocesan staff; volunteers; students; and other parish, or diocesan workers, including their families. I recognize that the PARISH, SCHOOL, AND DIOCESE OF GREENSBURG cannot limit all potential sources of COVID-19 infection and cannot guarantee that I/my child/a household member will not become infected with COVID-19.

I acknowledge that, by sending my child to parish activities, including but not limited to on-site faith formation and/or youth ministry, I am/my child/a household member is increasing risk of exposure to COVID-19. I voluntarily assume full responsibility for any and all risks of illness or injury associated with my/my child’s/my household members exposure to COVID-19, as well as from use of any protective equipment, including face coverings, that the PARISH, SCHOOL, AND DIOCESE OF GREENSBURG may voluntarily provide to my child.

I attest that:
1. My child is not experiencing any symptoms of illness such as cough, shortness of breath or difficulty of breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

2. My child has not traveled internationally within the last 14 days.

3. My child has not traveled to a state identified by the Pennsylvania Department of Health as having high amounts of COVID-19 cases in the last 14 days.

4. I do not believe my child has been exposed to someone with a suspected and/or confirmed case of COVID-19.

5. My child has not been diagnosed with COVID-19 and not yet cleared as non-contagious by state or local public health authorities.

6. I am following all CDC recommended guidelines and limiting my/my child’s exposure to COVID-19.

I understand that it is my responsibility to notify the PARISH if any of the aforementioned situations change throughout the year.

I agree that if I am/my child/a household member is exhibiting symptoms of illness such as cough, shortness of breath or difficulty of breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell, I will seek medical attention for me/my child/my household member, remain isolated and self-quarantine until I have/my child/my household member has been cleared by a medical professional.

In consideration for providing my child the opportunity to attend formation and parish activities and any related transportation to and from the parish, both my child and I voluntarily agree to release and agree to hold PARISH AND DIOCESE OF GREENSBURG harmless from, and waive on behalf of myself/my child, my heirs, and any personal representatives, any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself/my child that may be caused by any act, or failure to act of the PARISH AND DIOCESE OF GREENSBURG or that may otherwise arise in any way in connection with my child’s attendance at school to the fullest extent allowed by law.

I understand that this release discharges the PARISH, AND DIOCESE OF GREENSBURG from any liability or claim that I/my child, my heirs, or any personal representatives may have against the parish/school/diocese with respect to any bodily injury, illness, death, or medical treatment that may arise from, or in connection to, my child’s attendance at the parish.

This liability waiver and release extends to the PARISH, AND DIOCESE OF GREENSBURG  together with its clergy, staff, and volunteers.

I certify and represent that I have the legal authority to waive, discharge, release, and hold harmless the released parties on behalf of myself and the above-named student.

First Student Name

First Name*

Middle Name

Last Name*

Phone*
First Student Date of Birth*
I certify that I am 18 years of age or older
First Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
First Student Signature*
Second Student Name

First Name*

Middle Name

Last Name*
Second Student Date of Birth*
Second Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Third Student Name

First Name*

Middle Name

Last Name*
Third Student Date of Birth*
Third Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Fourth Student Name

First Name*

Middle Name

Last Name*
Fourth Student Date of Birth*
Fourth Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Fifth Student Name

First Name*

Middle Name

Last Name*
Fifth Student Date of Birth*
Fifth Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Sixth Student Name

First Name*

Middle Name

Last Name*
Sixth Student Date of Birth*
Sixth Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Seventh Student Name

First Name*

Middle Name

Last Name*
Seventh Student Date of Birth*
Seventh Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Eighth Student Name

First Name*

Middle Name

Last Name*
Eighth Student Date of Birth*
Eighth Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Ninth Student Name

First Name*

Middle Name

Last Name*
Ninth Student Date of Birth*
Ninth Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Tenth Student Name

First Name*

Middle Name

Last Name*
Tenth Student Date of Birth*
Tenth Student Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Student 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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Second Emergency Contact

F/L Name *

Telephone *
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*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Current School *

Grade *

Medical Illnesses or Allergies *

Prescription Medication *
Parent or Guardian's Signature*
Electronic Signature Consent*
I certify and represent that I have the legal authority to waive, discharge, release, and hold harmless the released parties on behalf of myself and the above-named student. 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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