Client's Full Name *

First Name

Last Name

Phone *

(###)

###

####

Session Date *

MM

DD

YYYY

Do you or anyone in your family have any of the following symptoms, fever, cough, shortness of breath, difficulty breathing, sore throat and/or running nose? *

Yes

No

Are you expecting a result from a Antigen/PCR test due to a suspected close contact? *

Yes

No

Did you have close contact with a person who has a probable or confirmed case of Covid 19 in the last 10 days? *

Yes

No

Have you or anyone in your family had a fever in the past 10 days? *

Yes

No

Waiver Release of Liability, Waiver of all Possible Claims and Assumption of Risk**Please review before signing**I hereby acknowledge that I have agreed to meet with Adriana Reyes, Photographer at Adriana Reyes Photography on 2 Farooq Blvd., Woodbridge, ON, L4H4P3 (the “Facility”) for the purpose of receiving photography services (the “Services”). I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while attending at the Facility, even with all implemented safety measures, procedures and protocols. I also acknowledge and accept that while receiving services, the photographer may need to be closer than the recommended social distancing guidelines in order to wrap or pose a baby or child. I acknowledge and confirm that I am willing to accept this risk as a condition of attending at the Facility to receive services from the photographer. In consideration of the photographer agreeing to see me in person at the Facility, I agree to release the photographer and the Facility (if applicable), their family, employees, and volunteers (the “Releases”) from any and all causes of action, claims, demands, requests, damages or any recourse whatsoever in respect of any personal injuries or other damages which may occur or arise as a result of exposure to COVID-19 during my visit to the Facility and/or through the provision of services to me by the photographer. I do hereby acknowledge and agree that notwithstanding the generality of the foregoing, I declare that I will not commence litigation or otherwise seek to recover damages or other compensation against the Releases based on any action, claim, demand, request, loss or any recourse whatsoever arising from any potential or actual exposure to COVID-19 while attending the Facility and/or through the provision of services to me by the photographer. I further acknowledge that the Releases can rely on this Release of Liability, Waiver of all Possible Claims and Assumption or Risk and acknowledge that I fully understand the terms as set out above. I acknowledge that I am signing this Release of Liability, Waiver of all Possible Claims and Assumption of Risk voluntarily. *

YES, I ACCEPT

NO, I DECLINE