1 Start 2 Complete Signer First Name * Last Name * Email * Please indicate which MNN Facility you are visiting: MNN Location * 59th St Firehouse I (AKA "the signer") consent to receive service from Manhattan Neighborhood Network during the COVID-19 outbreak. I understand there is much to learn about the newly emerged COVID-19, including how it spreads and is transmitted. I understand that, based on what the Centers for Disease Control (CDC) says is currently known about COVID-19, the spread is thought to occur mostly from person-to-person via respiratory droplets during close contact. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a period of time, or by having direct contact with infectious secretions from someone with COVID-19. I further understand that, although it is not the primary means of transmission, the CDC has indicated that it is possible that COVID-19 can spread by touching a surface or object that has the virus on it and then touching one’s mouth, nose or eyes. I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious. I understand that due to the unknowns of this virus; the number of other producers that have been in the facility; and the nature of the services provided here; that I have an increased risk of contracting the virus by being in, and by receiving services at the facility. I understand that the CDC and New York State Department of Health guidelines recommend social distancing and the use of protective gear (such as masks and gloves) as preventive measures. I understand that even with the facility following all CDC and New York State Department of Health guidelines for reducing COVID-19 infection risk in providing services, I am still at risk for possible infection with receiving such services at the facility at this time. * Agreed to by signer I understand that the services I am receiving are being provided to me by my sole discretion and desire. I confirm that I’m seeking those services voluntarily and understand the risks involved. * Agreed to by signer I understand that Manhattan Neighborhood Network has developed a protocol for ensuring social distancing and proper surface sanitation. I hereby confirm that I have read the policy and will comply with any and all elements of such protocols, including but not limited to wearing a mask at all times and maintaining social distancing. I understand that the symptoms listed below are representative of COVID-19: Fever Fatigue Dry Cough Shortness of Breath Muscle or Body Aches Persistent pain or pressure in the chest Bluish lips or face New loss of taste or smell I confirm that I, and those who live with me, have not displayed, or currently have, any of the symptoms that are representative of COVID-19, which are outlined above. * Confirmed by signer I confirm that, to the best of my knowledge, in the past 14 days I have not come into close contact with anyone who appeared to me as displaying, or having, any of the symptoms that are representative of COVID-19, which are outlined above. * Confirmed by signer I understand that all travelers arriving from a country or region with widespread ongoing transmissions should stay home for 14 days to practice social distancing and monitor their health after their arrival. Furthermore, I understand that pursuant to New York State Executive Order 205, any traveler entering New York from a state with a positive test rate higher than 10 per 100,000 residents or a higher than 10% test positivity rate over a seven day rolling average is required to quarantine for a period of 14 days, consistent with New York State Department of Health regulations for quarantine. The current list of states subject to these Travel Advisories is available at https://coronavirus.health.ny.gov/covid-19-travel-advisory I confirm that I, and those who live with me, have not returned in the last 14 days from traveling to any of the countries or regions with widespread ongoing transmission. * Agreed to by signer RELEASE OF CLAIMS By signing this agreement, I acknowledge and assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, or death. I hereby release, covenant not to sue, and hold harmless Manhattan Neighborhood Network, its employees, agents and representatives, of and from any claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind relating thereto, in any court of law or other adjudicatory government body. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of Manhattan Neighborhood Network, its employees, agents, or representatives located at the Facility. I understand this release means that I can never bring any claim for any money damages, nor for any other legal remedy/relief against the Facility and any of the staff members at the Facility. I acknowledge that I have read and understand this Service Consent and Release of Claims and that I knowingly and voluntarily have signed it as a condition of the Facility agreeing to provide services for me. 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