First & Last Name ___________________________________________

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PLEASE CHOOSE ONE OF THE FOLLOWING: 

I certify that I am fully vaccinated for COVID-19 and have provided proof of vaccination to Adrienne Dara Hair Salon. I understand that I have the option to wear a mask but am not required to do so. I affirm that by signing, my statement is true. 

 

 

X _____________________________________

 

I choose not to disclose my vaccine status. Therefore, I understand that I must wear a mask for the duration of my appointment.   

 

 

X _____________________________________

 

PLEASE “X” ONE OF THE FOLLOWING: 

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___ Option 1: I request that my fully vaccinated stylist wear a mask for the duration of my appointment.

 

___ Option 2: I am comfortable with my fully vaccinated stylist not wearing a mask.

                    

Assumption of the Risk and Waiver of Liability Relating to COVID-19 The novel coronavirus, COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. Adrienne Dara Hair Salon, has put in place preventative measures to reduce the spread of COVID-19; however Adrienne Dara Hair Salon cannot guarantee that you will not become infected with COVID-19. 

 

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 at Adrienne Dara Hair Salon and such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense of any kind, that I may experience or incur in connection with entering Adrienne Dara Hair Salon. 

 

On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Adrienne Dara Hair Salon and its employees of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Adrienne Dara Hair Salon and its employees whether a COVID-19 infection occurs before, during, or after coming to Adrienne Dara Hair Salon. 

 

In signing below, I hereby acknowledge and agree that I am executing this document in consideration of allowing myself to enter Adrienne Dara Hair Salon and for good and other valuable consideration the receipt and sufficiency of which is hereby acknowledged.

 

 

SIGNATURE AND DATE:

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