COVID19 Waiver

maskrequired This form gives the authorized person of the United Music & Arts Conference permission to see that you receive prompt medical attention, and that the information listed above is correct. This information will only be used in the event of an emergency. You are a vital part of this conference, your good health is important to us.

Your name

Birthdate

Gender / Preferred Pronoun

Your email

Address Line 1

Address Line 2

City

State

Zip

Phone

Emergency Contact Name

Emergency Address/City/State/Zip

Emergency Contact Phone

Emergency Contact Relationship to you

Emergency Contact Email

Enter any allergies

Enter your Insurance info

Covid19 Antigen/PCR Date performed

Covid19 Antigen/PCR Result

Participant Signature

By entering your name here, you effectively sign this document and agree to the terms below.

COVID-19 LIABILITY WAIVER AND ACKNOWLEGEMENT FORM
I acknowledge the contagious nature of the COVID-19 virus and acknowledge that the UMAC Conference adheres to the CDC recommendations of practicing social distancing and wearing face coverings where applicable. I further acknowledge that UMAC has put in place preventative measures to reduce the spread of the COVID-19 virus, to the best of their abilities. I further acknowledge that no guarantee exists regarding whether or not I may contract COVID-19. I understand that the risk of becoming exposed to and/or infected by the COVID-19 virus may result from the actions, omissions, or negligence of myself and others, including but not limited to, staff, volunteers and others. I acknowledge that I may increase my risk of exposure to COVID-19 by participating from time to time in UMAC activities or meetings. In the event a participant tests positive for COVID-19 within Forty-Eight (48) hours of the activity, I hereby waive confidentiality and authorize UMAC to disclose the participation list to the local public health authorities for the purpose of contact tracing.

I attest that: – I am NOT experiencing any symptom of illness such as cough, shortness of breath, difficulty breathing, fever, chills, muscle pain, headache, sore throat, or new loss of taste or smell. – I do not believe I have been exposed to someone with a suspected and/or confirmed case of COVID-19. – I have not been diagnosed with Coronavirus/COVID-19 within the previous 14 days.

I hereby release and agree to hold UMAC, its employees, and volunteers harmless from any causes of action, claims, demands, damages, costs, expenses, and compensation for damage to myself that may be caused by any act, or failure to act, or that may otherwise arise in any way while I am participating in UMAC activities or meetings. I fully understand that this release discharges the aforementioned from any liability with respect to bodily injury, illness, or medical treatment that may arise from, or in connection to my participation at the UMAC conference.