COVID-19 Informed Consent and Waiver of Liability and Indemnification

Hello Valerie’s House Family,

We are looking forward to seeing you again in person as groups resume in a safe environment for your family.

When you get the chance, please read through this document as it contains important information about the decision to resume in person groups during this time.

Thank you and see you soon,

The Valerie’s House Team

 INFORMED CONSENT TO ATTEND IN PERSON AT VALERIE’S HOUSE DURING COVID-19 PUBLIC HEALTH CRISIS

This document contains important information about our decision (yours and ours) to resume in person services in light of the COVID-19 public health crisis. Please read this carefully. 

I, Parent/Legal Guardian Signing this form, knowingly and willingly consent to participate in grief support groups and/or activities with Valerie’s House, Inc, during the COVID-19 pandemic for myself and/or the child(ren) listed on this form.

I understand that Valerie’s House, Inc, is taking the following precautions to protect families and help slow the spread of the coronavirus. 

• Each group room has been arranged for appropriate physical distancing and some items are not currently available for use to do cleaning procedures.

• Groups will be conducted with smaller numbers and the ability to maintain safe distancing in our interactions with each other and our families.

• Family members that will not be attending groups will he asked to wait in their vehicles until groups are over.  

• Group facilitators and staff will be wearing face coverings such as masks or face shields and we are asking your family to also wear a protective covering for the time being. We will make plenty of them available. This is to protect both of us. If you have a need that prevents you from wearing a face covering, please reach out to Amy Strom, Director of Programs and Bereavement.

• Hand sanitizer that contains at least 60% alcohol will be available for everyone to use in each group room, as you enter and as you exit. Hand washing is an alternate option. 

• Volunteers will be available to help families check in one at a time. You will see marks for distancing.

• Physical contact like hugging is not permitted at this time. Virtual High 5’s and Virtual hugs are needed!

• Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis. 

• Group materials will be created for your child to have on their own so they don’t have to worry about sharing with their friends. All Valerie’s House items and materials will be sterilized according to CDC Guidelines.

• We will be refraining from having dinner and we want to keep food out of the groups for now. Water will be available and surprise packaged snacks at the end of the night.

• Groups nights will be from 6:30 pm to 8:00 pm. We will close with the Valerie’s House traditional hug, but it will be an“elbow bump” or something else the kids might come up with that allows us to close with love.

• Common areas are thoroughly disinfected at the end of each day as well as throughout the day.

I/We are agreeing, based on this consent, to meet Face-to-Face/in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, we may initiate that we meet via our virtual platform only. 

Family’s Responsibility to Minimize Your Exposure:

In order to have our groups in person, your family agrees to take certain precautions which will help keep everyone safer from exposure. Including the following:

You agree that if you experience symptoms of COVID-19, or any potentially contagious symptoms, at any time within 14 days of your scheduled group, you will contact Valerie’s House staff and provide a doctor’s note of approval before coming to group.  

You will allow our staff/volunteer to take both your temperature and your child(ren)s temperature before entering group. If it is elevated (100.3 Fahrenheit or more), or if you have other symptoms of the coronavirus, you and anyone in your family agree may not be permitted to participate in Valerie’s House in-person that night.  You will be able to participate in virtual groups until you have a doctor’s note clearing you and your family members of any health issues that could be contagious to others.

• You agree to refrain from coming to Valerie’s House if you are presenting any of the following symptoms of COVID-19 listed below:

-Temperature above 100.3 degrees

-Shortness of breath

-Loss of sense of taste or smell

-Dry cough

-Sore Throat

-Nausea

-Rash

• You agree to adhere to the safe distancing precautions established in areas. You understand that the CDC, OSHA and the State of Florida recommend social distancing of at least 6 feet. 

• You are required to wear a face covering in all areas inside the house and recognize our team will be doing the same.

• You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.

• You agree to take steps between groups to minimize your exposure to COVID. You understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. At this time, it still difficult to determine who may have the virus and who does not.

• If a resident of your home tests positive for the infection, you will immediately let our team know.

• As COVID continues to develop and professionals know more about it, you recognize the information in this consent may change the above precautions.

• The limits of confidentiality are still in place, however if an exposure to COVID has occurred, my name (and/or child’s name) and contact information could be released to official public health workers. I will be notified prior to this occurring by Valerie’s House.

COVID -19 WAIVER OF LIABILITY AND INDEMNIFICATION

1.     I agree that I am personally responsible for my safety and actions while participating in any Valerie’s House gatherings, groups, appointments, or events. I agree to comply with all Valerie’s House policies and rules, including but not limited to all Valerie’s House policies, guidelines, signage, and instructions. Because Valerie’s House events are primarily group events, I recognize that I am at higher risk of contracting COVID-19. With full awareness and appreciation of the risks involved, I, for myself and on behalf of my family, spouse, estate, heirs, executors, administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and covenant not to sue Valerie’s House, Inc, its board members, officers, agents, servants, independent contractors, affiliates, employees, successors, volunteers, and assigns (collectively the “Released Parties”) from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by me related to COVID-19, whether caused by the negligence of the Released Parties, any third-party using any Valerie’s House office or facilities, or otherwise, while participating in any activity while in, on, or around the Valerie’s House office and/or while using the facilities of  Valerie’s House partners at Valerie’s House events and gatherings and/or while using any, tools, equipment, or materials.

2.     I acknowledge that COVID-19 is a highly contagious disease, is the source of a global pandemic, that information about COVID-19 is rapidly changing, and at this time there is no known treatment or cure for COVID-19.

3.     I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney fees) arising either directly or indirectly from or related to any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my participation in  Valerie’s House events and gatherings and/or my use of related facilities, tools, equipment, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19.

4.     By signing below, I acknowledge and represent that I have read the foregoing Waiver of Liability, understand it and sign it voluntarily as my own free act and deed, including without limitation the Release of Liability and Indemnification requirements contained in this document; I am sufficiently informed about the risks involved in participating in Valerie’s House events and gatherings to decide whether to sign this document; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this document for full, adequate, and complete consideration fully intending to be bound by the same and agree to these terms for my children and myself. I understand that I may also elect to participate in Valerie’s House virtually and physical presence is not required.  I agree that this Wavier of Liability shall be governed by and construed in accordance with Florida law, and that if any of the provisions hereof are found to be unenforceable, the remainder shall be enforced as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to permit enforcement of the Wavier of Liability as a whole.

5.     I understand that to participate in any Valerie’s House events, I must sign the Waiver of Liability form, the Informed Consent Form and agree to health screenings (temperature check, health questionnaire, etc.) before I may attend. I also agree to follow guidelines established by Valerie’s House Inc for both myself (caregiver) and my child(ren) and understand Valerie’s House makes no representation or warranty that by following the guidelines or directions from Valerie’s House that I will be fully protected from exposure to COVID-19.  I understand that the results from any health screening may inhibit my and/or my child’s ability to participate in in-person groups or event. In addition, in the event, my child attends an event without me as their guardian, I give my child(ren) permission to complete the health screening without my presence and will instruct them to answer accurately as I as their guardian will be held responsible for their responses.

6.     I understand that the following are symptoms of COVID-19: fever  or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea (“COVID-19 Symptoms”).  I certify that in the last 14 days, I have not experienced COVID-19 Symptoms or been in close contact with anyone with COVID-19 Symptoms or who has tested positive for the COVID-19 Virus.  If I develop any COVID-19 Symptoms, test positive for COVID-19, or am in close contact with someone with COVID-19 Symptoms or who has tested positive for COVID-19 prior to beginning Valerie’s House Activities, I will immediately notify Valerie’s House and I will not participate in Valerie’s House Activities.

7.     I agree to monitor myself for COVID-19 Symptoms daily using Valerie’s House’s Health Screen Form as designated VH representative as required. I certify that if, during the term of the Activities, I develop any COVID-19 Symptoms, test positive for COVID-19, or am in close contact with someone with COVID-19 Symptoms or who has tested positive for COVID-19, I will immediately notify Valerie’s House and cooperate with any isolation, quarantine or relocation required by the Valerie’s House. 

8.     I acknowledge that if I develop COVID-19 Symptoms during my participation in the Activities or test positive for COVID-19, the Valerie’s House will notify those with whom I have been in contact and government officials, as appropriate.