COVID-19 Waiver COVID-19 Waiver "*" indicates required fields First Name*Last Name*Phone Number*EmailNumber of additional people in your group (do not count yourself)Location* Payne Recreation Center Gerhardt Civic Center Event/Program/Class* General Workout Aerobics Class Gym (basketball) Pickleball Quilting Has any member of your group traveled in the last 2 weeks to any area that would require a quarantine?* Yes No Has any member of your group in the last 2 weeks had a fever or chills, cough, sore throat, difficulty breathing, vomiting or diarrhea?* Yes No Has any member of your group in the last 2 weeks been exposed to someone who has tested positive for COVID-19?* Yes No IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE, WE REQUEST THAT YOU DO NOT PARTICIPATE TODAY.Acknowledgement/Signature*The COVID-19 coronavirus is an extremely contagious virus that spreads easily through contact with infected persons and objects. You acknowledge that you may be exposed to and infected with COVID-19 through the use of City of Moraine facilities or participation in a program sponsored or conducted by City of Moraine. You further understand and acknowledge that the risk of exposure to and infection with COVID-19 cannot be fully eliminated, and City of Moraine in no way warrants that COVID-19 exposure or infection will not occur, if you choose to use City of Moraine Recreation Center facilities or participate in a program sponsored or conducted by City of Moraine. You willingly, freely and voluntarily agree to assume all risks of exposure to and infection with COVID-19 arising out of or in any way related to use of City of Moraine Center facilities or participation in a program sponsored or conducted by City of Moraine. City of Moraine is doing its part to stop the spread of COVID-19 by assisting in contact tracing efforts in compliance with recommendations from the Ohio Department of Health. City of Moraine shall maintain daily entry logs and may be required to share these records upon lawful request of a local department of health or the Ohio Department of Health. You understand that, as a condition to using the City of Moraine Recreation Center facilities or participating in a program sponsored or conducted by the City, you authorize the City to maintain records and to release such records upon lawful request of a local department of health or the Ohio Department of Health. For and in consideration of permission to use the above described facility(ies), and for other good and valuable consideration, it is understood and agreed this agreement is made upon the express condition that the City of Moraine, Ohio, and the Moraine Parks and Recreation Division, and all of their respective employees, officers, agents, elected and appointed officials, and representatives shall be free from any and all liabilities and claims for damages and/or suits for or by reason of any injury, death, or damage to any property of the participant, from any cause or causes whatsoever while in or upon the said facility(ies), or any part thereof, during the term of this agreement. Participant hereby agrees to release and discharge from any and all liability arising in any way from the rental and/or use of the above described facility(ies), the City of Moraine, Ohio, and the Moraine Parks and Recreation Division, and all of their respective employees, officers, agents, elected and appointed officials, and representatives. Participants covenants and agrees to indemnify, defend, save and hold harmless the City of Moraine, Ohio, and the Moraine Parks and Recreation Division, and all of their respective employees, officers, agents, elected and appointed officials, and representatives from any and all liabilities, claims, suits or losses however occurring and any and all damages arising out of same. I/We have had sufficient time to read this document. I/We have read and understand this document and agree to be bound by its terms. Agree
