Onsite Attendance Registration Form
Only those that have registered and received a confirmation email/text will be allowed to enter (No Exception), so please print or save a copy of your confirmation email/text and bring along with you on the date of the program.

Note that once we reach our intended capacity, registration will be closed.
INFORMED CONSENT
To do our part in preventing the spread of COVID-19 in our community and places of worship, and for the well-being and safety of our members, we are restricting access to MASOM's premises for anyone who is below the age of 18 and for anyone who may have recently been exposed to the virus.

Please read this carefully.

By submitting this form, you are affirming and attesting that:

(a) You are 18 years of age or older; AND

(b) You have not in the last 14 days had any close contact with anyone who is either confirmed or suspected of being infected with COVID-19, including anyone who was experiencing or displaying any of the known symptoms of COVID-19 (which are listed in item (d) below); AND

(c) You have not in the last 14 days traveled to a restricted area that is under the Travel Advisory according to the U.S. State Department or to any U.S. State included in City of Chicago's Emergency Travel Order.

(d) You do not currently experience or display, and you have not in the last 14 days experienced or displayed, any of the following symptoms:
• Elevated temperature or fever of 100.4 F or higher,
• Cough,
• Shortness of breath and/or difficulty breathing,
• Loss of smell and/or taste,
• Fatigue, muscle aches, chills, shaking, or
• Persistent headaches.

If you cannot answer "YES" to any of the above statements, you should not proceed with the registration.


Thank you for your cooperation,

Management of MASOM
Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and is extremely contagious. COVID-19 can cause serious and potentially life threatening illness and even death. The Midwest Association of Shia Organized Muslims (“MASOM”) cannot prevent you [or your child(ren)] from becoming exposed to, contracting, or spreading COVID-19 while on MASOM premises. It is not possible to prevent against the presence of the disease. Therefore, if you choose to enter onto MASOM’s premises you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19.

ASSUMPTION OF RISK: I have read and understood the above warning concerning COVID-19. I hereby choose to accept the risk of contracting COVID-19 for myself [and/or my child(ren)] in order to enter MASOM’s premises. These programs and services are of such value to me [and/or to my child(ren),] that I accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to enter MASOM’s premises and attend prayer service and other programs in person.

WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against MASOM and its officers, directors, managers, officials, trustees, agents, employees, members, participants, volunteers or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to entering MASOM’s premises and attending prayer service or programs there. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen.

CHOICE OF LAW: I understand and agree that the law of the State of Illinois will apply to this contract.


I AM 18 YEARS OF AGE OR OLDER. I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE: *
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