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PVCC Workforce Services
PVCC Workforce Services
|COVID-19 Assumption of Risk Form|
ACKNOWLEDGEMENT OF THE RISK FORM
I agree that as a participant in a class at the Stultz Building, PVCC Main campus or the Jefferson School Center associated with the Piedmont Virginia Community College. I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been informed of the general nature of the risks involved in this activity, including, but not limited to slips and falls, injuries, and contracting diseases such as COVID-19, also known as the coronavirus disease.
COVID-19 is a pandemic of respiratory disease that spreads from person-to-person. COVID-19 can cause mild to severe illness; most severe illness occurs in older adults. Nevertheless, people of all ages with severe chronic medical conditions including, but not limited to, heart disease, lung disease, and diabetes are also at a higher risk of developing serious COVID-19 illness. Healthcare workers caring for patients with COVID-19 have a higher risk of exposure and I understand that the instructional sites, labs, or clinical facilities may have people recovering from COVID-19. At this time, there is no vaccine to protect against COVID-19 and no medications approved to treat it.
Symptoms of COVID-19 include fever, cough, and shortness of breath. Reported illnesses range from very mild (including some with no reported symptoms) to severe, including death. If I feel sick, I agree not to go to the instructional site/lab/clinical facility and that I will stay home, except to receive medical attention if necessary. I also agree to take all necessary precautions recommended by the Centers for Disease Control and Prevention, including but not limited to washing my hands thoroughly and often, avoiding gatherings of ten or more people, covering my mouth and nose if I cough or sneeze, and avoiding public transportation, ride-sharing, or taxis to the greatest extent possible.
I agree to abide by any and all specific requests by the College and the instructional site/lab/clinical facility for my safety or the safety of others, as well as any and all of the College’s and the instructional site/lab/clinical facility’s rules and policies applicable to all activities related to this program. I understand that the College and the instructional site/lab/clinical facility reserve the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of others.
In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby agree that I am responsible for any resulting personal injury or illness which may occur as a result of my participation or arising out of my participation in this program, unless any such personal injury or illness is directly due to the negligence of the College and/or the instructional site/lab/clinical facility. I understand that this Acknowledgement of Risk form will remain in affect during any of my subsequent visits and program-related activities, unless a specific revocation of this document is filed in writing with Dean of Workforce Services, at which time my visits to or participation in the program will cease.
I have read and understand the risks involved in participating in an education program at an instructional site/lab/clinical facility during this pandemic. I understand that I have the option to postpone any clinical placement or on-campus assignment without academic penalty. I also understand that I must complete the requisite number of clinical hours or other requirements to complete the health professional or other academic program in which I am enrolled. If I choose to postpone any clinical placement or on-campus assignment, I understand that my progression within the health professional or other academic program will be delayed.
I acknowledge that I have read and fully understand this document. I further acknowledge that I am accepting these personal risks and conditions of my own free will.
I represent that I am 18 years of age or older and legally capable of entering into this agreement.
If participant is less than 18 years of age, the following section must be completed:
My child/ward is under 18 years of age and I am hereby providing permission for him/her to participate in this program, and I agree to be responsible for his/her behavior and safety during this event.
__(See Below)____ Child’s Name ____(Complete Address Below)___ Address
__(Sign Below)____ Parent’s or guardian’s signature