Flu Waiver Form
Love to Share Foundation America - Waiver for Voluntary Participants of Influenza Vaccinations


As a condition and in consideration of being permitted to take an influenza vaccination (“flu shot”) offered by Love to Share Foundation America, this waiver is signed by me and undertaken by me at the request of Love to Share Foundation America.

I admit that I am NOT a recipient of Medicare/Medicaid benefits and I do not hold any private medical insurance. I hereby RELEASE, WAIVE, DISCHARGE, HOLD HARMLESS AND COVENANT NOT TO SUE LOVE TO SHARE FOUNDATION AMERICA, their partners, vendors, agents and officers, and the owners and lessees of premises used for conducting the flu shots offered by Love to Share Foundation America, (hereinafter referred to as “releasees”) from all liability for any and all loss or damage, and any claim or cause of action therefore on account of injury to myself or Property or resulting in death, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE due to/resulting from the undersigned’s participation in the flu shots administered by Life and Soul 2018, the free health fair.

1. I understand and acknowledge that no person is required to participate in flu shots.

2.I HEREBY ASSUME FULL RESPONSIBILITY FOR RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE DUE TO THE ACTS, OMISSIONS OR NEGLIGENCE OF RELEASEES OR OTHERWISE while participating in flu shots.

3.I EXPRESSIVELY ACKNOWLEDGE AND UNDERSTAND that the flu shot being administered can be dangerous and involves the risk of physical injury and/or death

4. I further expressly agree that the foregoing waiver is intended to be as broad and inclusive as is permitted by the state and, if any portion thereof is held invalid, it is agreed that the remainder continues to have full legal force and effect.5. I HAVE READ AND VOLUNTARILY SIGNED THE WAIVER AND RELEASE OF LIABILITY AGREEMENT, AND I FURTHER AGREE THAT NO ORAL REPRESENTATIONS OR STATEMENTS OF INDUCEMENT APART FROM THE ONGOING WRITTEN AGREEMENT HAVE BEEN MADE. I HAVE READ THIS DOCUMENT, AND UNDERSTAND THAT I ASSUME ALL RISKS INHERENT IN TAKING A FLU SHOT. I VOLUNTARILY SIGNED MY NAME EVIDENCING MY ACCEPTANCE OF THE ABOVE PROVISIONS.
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Do you have any allergy to eggs? *
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Do you have any other serious allergies? *
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Have you ever had a serious reaction to a previous dose of Flu Vaccine? *
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Have you ever had Gullain Barre Syndrome within six weeks of receiving the flu vaccine? *
I have read the 2019-2020 Vaccine Information Statement for the seasonal Influenza Vaccine and understand the risks and benefits.
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