Form Template | Birth Partners of CT

Covid-19 Liability Release Waiver

*This form must be submitted prior to completing your postpartum client worksheet

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the government has set recommendations, guidelines, and some prohibitions to which Birth Partners, LLC. (the "Organization") and your doula adhere including mask and glove wearing, and distancing when possible, while under your employ.

I am fully and personally responsible for my own health and safety and the health and safety of my family while having a doula support me and/or my family, in or at my home and/or birthplace at my request. I recognize and acknowledge that this could put me/us at risk of contracting COVID-19 and that there is risk in hiring a doula to come to my home and/or birthplace, that may include injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.

With full knowledge of the risks involved, I hereby release, waive, discharge Birth Partners LLC, its owner, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while having a doula in my employ that may lead to unintentional exposure or harm due to COVID-19.

I agree to indemnify, defend, and hold harmless Birth Partners LLC, its owner, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.

First Name

Last Name

By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation.

Your Signature

Date

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