Child Life Disaster Relief COVID-19 Informed Consent Form

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Child Life Disaster Relief (CLDR) is aware and constantly monitoring the COVID-19 pandemic, especially how it will affect CLDR. If necessary, changes or cancellations may be made based on federal or state level travel restrictions, official guidance changes or direction from local partners. CLDR responders MUST comply with ALL the precautions listed below. If you feel you are not able to comply or are not comfortable serving under these circumstances, you should not proceed with a disaster response deployment. COVID-19 Symptoms If you experience any of the following symptoms, it is your responsibility to report these symptoms to authority: Fever Cough Shortness of breath and difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea, vomiting, or diarrhea *

I have read and understand the information above.

Required

The following are a general overview of personal safety measures for current CLDR volunteers before they arrive and during CLDR deployments. Additional protocol may also take place that is under the direction of the community agency lead. Before CLDR deployment Participants are expected to follow these guidelines: Opt-out of deployment if exhibiting symptoms of any illness before meeting or deployment. Participants are recommended to monitor their temperature 3 days prior to event and not respond if it has been above 100 degrees during any of these checks. Opt-out of deployment if they have been in contact with someone in the last 14 days who has tested positive, is waiting on a test result for COVID-19, or is experiencing symptoms of COVID-19. Opt-out if they are not comfortable deploying or volunteering or observing ALL the safety protocols listed. Opt-out of COVID-19 vaccine has not been received in-full according to current CDC recommendations. *

I have read and understand the information above.

Required

Face coverings are required, and participants must bring their preference from home to be used. (valve N95 not permitted). Participants must always wear face coverings over their nose and mouth except when eating or drinking. When eating a meal, participants should sit 6 feet apart before removing a mask. Participants must always put their mask on prior to standing and leaving the table. Frequently wash hands for 20 seconds and/or wipe off gloves with a cleaning wipe especially before removing your mask or touching your face. When running water and soap are not available, use hand sanitizer containing at least 60% alcohol. Gloves are strongly recommended on the job site unless the task prohibits this. Coughing or sneezing must be done into the elbow. Participants should avoid touching their face as much as possible and should wash their hands with soap and water or use hand sanitizer before touching any part of their face. Participants should report any symptoms of any illness to leadership immediately or if they have tested positive for COVID-19 within 14 days after volunteering. *

I have read and understand the information above.

Required

By my filling out this form, I acknowledge that I am voluntarily agreeing to participate as a CLDR volunteer with knowledge of the danger involved. I hereby agree to accept and assume all risks of personal injury, illness, disability, death, or property damage or any other injury, arising from my serving as a volunteer, whether caused by the negligence of CLDR or otherwise. I hereby indemnify, defend and hold harmless Child Life Disaster Relief including expressly waiving and releasing any and all claims, now known, hereafter known, or arising out of my service, against Child Life Disaster Relief and its officers, directors, employees, agents, volunteers, affiliates, owners, successors, and assigns (collectively, "Releasees"), on account of injury, illness, disability, death, or property damage arising out of or attributable to participating as a CLDR volunteer, whether arising out of the negligence of CLDR or any Releasees or otherwise. I covenant not to make or bring any such claim against CLDR or any other Releasee, and forever release and discharge CLDR and all other Releasees from liability under such claims. I have read and agree to abide by all of the above mentioned safety procedures at all times when on a CLDR response. If I do not, I know I am not able to respond in person or deploy with CLDR. *

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