I understand that all reasonable precautions have been taken by the Kay Phillips Child Advocacy Center (KPCAC) to ensure health and safety of it’s employees, partners, visitors, and clients within the organization. I have been informed that the KPCAC is stringently following CDC and state guidelines for cleaning, disinfecting and sanitization. COVID-19 health guidelines are changing rapidly and the KPCAC has pledged to continue to follow these guidelines.

By signing this COVID-19 Waiver of Liability, I acknowledge and voluntarily assume full responsibility for, and full risk of personal or psychological injury, including death, relating to COVID-19 and my participation in my and the minor child(ren)’s, listed below, visit to KPCAC. To the fullest extent permitted by law, I hereby release, waive, discharge and covenant not to sue KPCAC, its individual officers, administrators, employees and agents, acting officially or otherwise, from any and all liability for a COVID-19 exposure/infection allegedly arising from my visit to KPCAC, including, but not limited to, liability for personal or psychological injury, including death.

By signing this form, I grant my permission for written and verbal information to be exchanged between KPCAC staff and agencies which have signed MOA’s for the purpose of evaluation, treatment, follow up, coordination, and problem resolution with reference to the identified client and family. I understand this may include mental health records covered under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45 C.F.R., Parts 160 and 164. If representatives from agencies not listed on the back of this form are present during the case management interdisciplinary process, each participant will have signed a statement of confidentiality and is bound by laws of confidentiality.

I further agree to hold harmless and indemnify KPCAC against any liability arising from my negligence or otherwise and from damages of any kind as a result of my participation in visiting KPCAC. I acknowledge that it is my sole responsibility to evaluate carefully the risks inherent in visiting KPCAC and I have considered those risks, including, without limitation, dangers posed by COVID-19 and willful or negligent conduct of myself and/or by others. I agree that if any portion of this document is held invalid, the remaining provisions shall be binding and continue in full force and effect.

I HAVE READ THIS COVID-19 WAIVER OF LIABILITY, UNDERSTAND ITS SIGNIFICANCE, AND VOLUNTARILY AGREE TO ALL OF ITS TERMS.