"Covid-19 General Waiver and Release of Liability for in-Person Visiting" - Michigan

Covid-19 General Waiver and Release of Liability for in-Person Visiting is a legal document that was released by the Michigan Department of Corrections - a government authority operating within Michigan.

Form Details:

  • Released on March 19, 2021;
  • The latest edition currently provided by the Michigan Department of Corrections;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Michigan Department of Corrections.

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Michigan Department of Corrections
COVID-19 General Waiver and Release of Liability for In-Person Visiting
Due to the ongoing novel Coronavirus (COVID-19) pandemic, the Michigan Department of Corrections is taking
extra precautions when resuming in-person visiting.
Symptoms of COVID-19 may include:
Fever of 100.4+ degrees
New onset of headache
Chills, sweats, or shaking
New loss of taste or smell
New or worsening cough
New sore throat
New or worsening shortness of breath
Nausea or vomiting
Sudden fatigue
Abdominal pain
Muscle or body aches
Diarrhea
By initialing each box, I agree to the following:
I understand the above symptoms and affirm that I—and members of my household—do not have and have
not experienced the symptoms listed above within the last 14 days.
I acknowledge that my temperature reading today was less than 100.4 degrees and my antigen test was
negative.
I affirm that I—and members of my household—have not been diagnosed with COVID-19 in the past 20 days.
I have not knowingly been exposed to anyone diagnosed with or suspected of having COVID-19 within the past
14 days.
I understand that the Centers for Disease Control (CDC) has stated that there is evidence that persons with
COVID-19 may be asymptomatic or pre-symptomatic, and that the virus may be transmitted to others by me if
I am such a carrier.
I understand that I am being allowed to visit during a pandemic, and that I must follow all visitation rules and
requirements, including but not limited to:
Wearing an appropriate mask over my nose and mouth for the duration of my visit.
o
Being mindful of social distancing, keeping 6 feet away while in common areas. No physical contact except
o
one embrace at the beginning and end of the visit.
Practicing good handwashing hygiene and utilizing available hand sanitizer.
o
I understand that despite adhering to all precautions, there is still a possibility that I will be exposed to or
contract COVID-19.
Persons with underlying health conditions may be particularly susceptible to illness and death from COVID-19.
Such conditions include, but are not limited to: heart disease, lung disease, suppressed immunity system, obesity,
diabetes, kidney disease, liver disease, etc. I have been advised and willingly choose to visit, understanding my own
health condition(s).
I have read the above and understand it is not inclusive of all risks and safety measures related to COVID-19. I am
choosing to visit a prisoner incarcerated with the Michigan Department of Corrections during the pandemic. In
accordance with applicable law and facility policy, I agree to enter into this general wavier and release of liability.
By signing this agreement, I waive and release the State of Michigan, its agencies, employees, agents, predecessors,
successors and indemnors, heirs and assigns, from any and all liability, including claims, demands, obligations,
actions, causes of action, damages, costs, and fees, whether based on a tort, contract, or any other theory of recovery,
legal or equitable, arising out of my contracting COVID-19.
I have read and voluntarily sign this agreement effective as of the date set forth below.
1.
Name:
2.
Facility:
Signature
Date
Updated 3/19/2021
Michigan Department of Corrections
COVID-19 General Waiver and Release of Liability for In-Person Visiting
Due to the ongoing novel Coronavirus (COVID-19) pandemic, the Michigan Department of Corrections is taking
extra precautions when resuming in-person visiting.
Symptoms of COVID-19 may include:
Fever of 100.4+ degrees
New onset of headache
Chills, sweats, or shaking
New loss of taste or smell
New or worsening cough
New sore throat
New or worsening shortness of breath
Nausea or vomiting
Sudden fatigue
Abdominal pain
Muscle or body aches
Diarrhea
By initialing each box, I agree to the following:
I understand the above symptoms and affirm that I—and members of my household—do not have and have
not experienced the symptoms listed above within the last 14 days.
I acknowledge that my temperature reading today was less than 100.4 degrees and my antigen test was
negative.
I affirm that I—and members of my household—have not been diagnosed with COVID-19 in the past 20 days.
I have not knowingly been exposed to anyone diagnosed with or suspected of having COVID-19 within the past
14 days.
I understand that the Centers for Disease Control (CDC) has stated that there is evidence that persons with
COVID-19 may be asymptomatic or pre-symptomatic, and that the virus may be transmitted to others by me if
I am such a carrier.
I understand that I am being allowed to visit during a pandemic, and that I must follow all visitation rules and
requirements, including but not limited to:
Wearing an appropriate mask over my nose and mouth for the duration of my visit.
o
Being mindful of social distancing, keeping 6 feet away while in common areas. No physical contact except
o
one embrace at the beginning and end of the visit.
Practicing good handwashing hygiene and utilizing available hand sanitizer.
o
I understand that despite adhering to all precautions, there is still a possibility that I will be exposed to or
contract COVID-19.
Persons with underlying health conditions may be particularly susceptible to illness and death from COVID-19.
Such conditions include, but are not limited to: heart disease, lung disease, suppressed immunity system, obesity,
diabetes, kidney disease, liver disease, etc. I have been advised and willingly choose to visit, understanding my own
health condition(s).
I have read the above and understand it is not inclusive of all risks and safety measures related to COVID-19. I am
choosing to visit a prisoner incarcerated with the Michigan Department of Corrections during the pandemic. In
accordance with applicable law and facility policy, I agree to enter into this general wavier and release of liability.
By signing this agreement, I waive and release the State of Michigan, its agencies, employees, agents, predecessors,
successors and indemnors, heirs and assigns, from any and all liability, including claims, demands, obligations,
actions, causes of action, damages, costs, and fees, whether based on a tort, contract, or any other theory of recovery,
legal or equitable, arising out of my contracting COVID-19.
I have read and voluntarily sign this agreement effective as of the date set forth below.
1.
Name:
2.
Facility:
Signature
Date
Updated 3/19/2021