Your Name (required)

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Is your child attending? YesNo

If yes, fill this out. One form must be filled for each child.
Child's Name

Child's Age

COVID-19 Screening*
Please be sure you can answer “NO” to ALL of these questions. If not, please DO NOT complete the form, stay home and enjoy the service online:

-Do you have a fever, new or existing cough or difficulty breathing?
-Have you returned from travel outside United States in the last 14 days?
-Have you had contact with a confirmed or suspected case of COVID-19?
-Have you been asked to self-quarantine by Public Health or had contact with anyone who has been told to self-quarantine themselves?

YesNo

Have you attended service at Fulfillment Temple before?*
YesNo

WAIVER
I acknowledge that I am between the ages of eighteen and sixty-five years old

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that many public health authorities still recommend practicing social distancing.

I understand the health risks implied with being in close proximity of other Fulfillment Temple attendees, specifically regarding COVID-19.

Regardless of the risk of exposure to, and contraction of COVID-19, I knowingly and voluntarily assume all risks and hazards which are direct or incidental to my attendance in, and participation of the Fulfillment Temple service(s) and knowingly and voluntarily waive any and all claims, actions or causes of action against Fulfillment Temple and agree to hold Fulfillment Temple, it’s officers, agents and other volunteers harmless of any possible exposure to, and contraction of Covid-19 that I may experience.

I hereby release and agree to hold Fulfillment Temple, its officers, trustees, members, employees, affiliates and contractors harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of Fulfillment Temple, or that may otherwise arise in any way in connection with my attendance or participation at Fulfillment Temple services. I understand that this release discharges Fulfillment Temple from any liability or claim that I, my heirs, or any personal representatives may have against Fulfillment Temple with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to my attendance at any Fulfillment Temple services. This liability waiver and release extends to Fulfillment Temple together with its officers, trustees, members, employees, affiliates and contractors.

I agree to defend, indemnify and save Fulfillment Temple harmless from and against any and all Liabilities, damages, losses, costs, claims or expenses (including but not limited to legal fees) to the maximum extent allowable by law, from any and all claims arising directly or indirectly from infection, death or other damages to me, my heirs or assigns or any third party for claims, suits or related causes of action asserted against Fulfillment Temple arising from my conduct.

I further acknowledge and agree that Fulfillment Temple has not assumed the duty to act as a common carrier and is not responsible for the actions of any persons, companies, or other entities who provide transportation, or any other services. I acknowledge and discharge Fulfillment Temple from any duty or legal responsibility for or relating to the selection or use of any carrier companies, or other entities, and I understand that Fulfillment Temple is not affiliated with or jointly responsible for the actions of any persons, companies, or entities.

I agree to abide by the rules and guidelines provided to me by the Fulfillment Temple in respect of the Service(s).

By clicking submit, you accept the terms and conditions of the waiver*