Assumption of Risk Waiver and Agreement Regarding Immunization Against COVID-19

Questions marked with a * are required

All individuals who do not complete vaccination for any reason must complete this Assumption of Risk Form, which defines the mitigation strategies that will be required of those who have not been fully vaccinated.

I understand that this Assumption of Risk form will remain in effect during any of my subsequent visits and program-related activities unless a specific revocation of this document is filed in writing to the James Madison University Lifelong Learning Institute, at which time my participation in the program will cease.

COVID-19 is a highly contagious respiratory virus that affects people of all ages. This virus can cause long-term medical problems and death regardless of age. This virus spreads through respiratory secretions related to speaking, singing, yelling, coughing, and sneezing. Infected individuals can spread the virus to others.

Prevention strategies include wearing a mask and physically distancing when around others.

The COVID-19 vaccines are very safe and highly effective at preventing death and hospitalization. When large numbers of people within a population are immunized, viral spread will be significantly limited. Each individual within a community can contribute to this protective approach.

Side effects related to vaccination primarily include pain at the injection site, headache, fever, and chills or body aches that last for about 24 hours.

Choosing to forego vaccination puts one at risk for getting the disease with the associated risk of long-term medical problems or death. Individuals who elect not to be vaccinated against COVID-19 may put others they interact with at risk. Due to this risk to others, JMU reserves the right to require those not vaccinated to engage in risk mitigation practices such as wearing masks or other personal protective equipment (PPE), submitting to regular screening tests, and isolating or quarantining off campus should they develop or be exposed to COVID-19. By choosing not to be vaccinated, people run a greater risk of becoming ill with COVID-19 and will be required to isolate per CDC guidelines if they become infected. Those not vaccinated against COVID-19 and exposed to someone with the disease will be required to quarantine for up to 14 days.

AGREEMENT

I have read and reviewed the information provided above concerning the risks and benefits of the COVID-19 vaccine. For personal reasons, I have chosen NOT to be vaccinated and therefore I accept the consequences associated with this decision.

I acknowledge this by agreeing to each of the following:

I agree to engage in reasonable risk mitigation practices as required by the university, including the use of PPE, entry testing, and submission to regular screening tests.

I agree to immediately notify the Lifelong Learning Office if I test positive for COVID-19 or have a known or suspected exposure to someone with the virus.

I agree to isolate or quarantine off campus if required by the university or the Virginia Department of Health.

I understand that, in the occurrence of an outbreak, I may be asked to refrain from visiting campus for my own protection and the protection of others until the danger has passed.

I agree to assume the risk that I may be exposed to, and become sick from, COVID-19 and to hold the university and its employees harmless from the consequence or effects caused by such illness.

I have had the opportunity to read this document and ask questions about it. I now voluntarily sign below to demonstrate my understanding of it and my commitment to abide by it.

Digital Signature:

First Name

Last Name

Email Address

Date Signed: