Love Life Activate and Margaret Dembinski agree to take all reasonable precautions in accordance with the government guidelines and recommendations regarding Covid-19. This includes myself and other practitioners and staff present are in the best health and do not exhibit an symptoms of illness. As an attendee, you agree to take full responsibility for your own health and awareness in the space within which you willingly enter. Please indicate agree or disagree beside each statement.

Agree

Disagree

I confirm that to the best of my knowledge I do not have Covid-19 *

Yes

No

I confirm that I do not have any symptoms of Covid-19, including but not limited to: Fever, aches and pains, a sore throat, difficulty breathing, a cough, etc. *

Agree

Disagree

I confirm that I have not been in contact with anyone with Covid 19 to the best of my knowledge. *

Agree

Disagree

I confirm that I have not been outside of the country within the past 14 days. *

Agree

Disagree

I understand that If I exhibit any symptom of illness that it is my responsibility to inform the teacher or practitioner and immediatly leave the space for the health and safety of all present. *

Agree

Disagree

I agree to monitor my own health and to leave the building, not return and seek appropriate medical attention if: I start to feel sick for any reason, I start to exhibit any symptoms of Covid-19, or if I learn that anyone I live with indicates they have symptoms or are in contact with Covid-19 *

Agree

Disagree

I understand that if I do not feel comfortable I can leave at any point in time by my own free will. *

Agree

Disagree

I agree that it is my responsibility to maintain a physical distance of 6 feet where ever possible. *

Agree

Disagree

I agree to wash and/or sanitize my hands and do my best to avoid touching my own mouth, nose, eyes, and ears as is recommended by health officials to avoid risk of spread of any infections disease. *

Agree

Disagree

I understand that it is recommended to wear a face mask unless you have a medical condition that prevents you from doing so. *

I understand

I don't understand

I understand that if I am over the age of 60, I have an increased risk of Covid-19 and complications *

I understand

I don't understand

I confirm that I am attending this event of my own free will and choice. *

Yes

No

I, (enter your name below), take full responsibility and recognize all inherent risks for my health and agree to not hold Margaret Dembinski or the Modern Mystery School, its instructors, staff, teachers, practitioners, or other attendees responsible in any way shape or form, should I contract Covid-19. *

I, (enter your name and initial below), accept and acknowledge the statements above have been made of my own free will, with sound body and mind. *

Name *

First Name

Last Name

Signature *

You can sign by signing your name like this: /Margaret Dembinski/ . Thank you!!

First Name

Last Name

Date *

MM

DD

YYYY