You can read and download the SRVIC CONSENT FORM FOR COVID-19.
I understand and acknowledge that COVID-19 virus is highly contagious and can spread by being in close proximity to another person. I also understand that the virus can live on and be transmitted through contact with surfaces. While there is presently no vaccine available for COVID-19, I have elected to leave my home and visit San Ramon Valley Islamic Center facility (“SRVIC”). I was and am under no obligation to come to SRVIC and do so at my own accord. I further acknowledge that I do NOT have any significant respiratory issues, compromised immune system, or other factors that put me at a high risk for contacting COVID-19.
I acknowledge and agree that before entering SRVIC facility each time, I will be required to undergo a temperature check, with additional screening (“Screening”). I understand that the Screening is not diagnostic, and it only seeks to determine whether I have symptoms currently associated with COVID-19. I acknowledge that the Screening does not create a patient/healthcare provider relationship with SRVIC and that I should seek medical advice if I have any questions or concerns regarding my health or the outcome of the Screening. I hereby authorize SRVIC to take my temperature reading and inquire regarding my potential exposure to, and symptoms associated with, respiratory illnesses such as COVID-19. I acknowledge that the lack of an elevated temperature reading or symptoms does not mean that I do not have COVID-19.
I also acknowledge that I have read, understood and hereby agree to abide by the instructions, directions and conditions required by SRVIC for visiting its facility. I understand that SRVIC has made this document available to me and that I have had the opportunity to review and understand this document prior to signing.
I ALSO AGREE NOT TO HOLD SRVIC LIABLE IN THE EVENT I, OR ANY MEMBER OF MY FAMILY OR ANY PERSON WHO RESIDES WITH ME, IS DIAGNOSED WITH COVID-19. THIS DOCUMENT IS INTENDED TO BE AND IS A BINDING AGREEMENT THAT AFFECTS MY RIGHTS AND MY ABILITY TO HOLD OTHERS RESPONSIBLE/LIABLE FOR ANY DAMAGES, INJURIES, OR CLAIMS I MAY OTHERWISE HAVE. THIS DOCUMENT SUPERSEDES ANY CONTRARY TERMS IN MY MEMBERSHIP AGREEMENT. I HAVE READ AND UNDERSTAND THIS FORM. I AM VOLUNTARILY SIGNING THIS CONSENT AND HAVE DONE SO WITHOUT DURESS OR UNDUE INFLUENCE. I FURTHER UNDERSTAND THAT, BY SIGNING IT, I AM RELEASING CERTAIN LEGAL RIGHT I MIGHT HAVE OTHERWISE.