MEDICAL WAIVER AND RELEASE OF LIABILITY FORM

I, the Participant, assume all risks associated with participating in any and all activities related to this occurrence, including, by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released; from dangerous or defective equipment or property owned, maintained, or controlled by any such persons; or due to their possible liability without fault.

I certify that I have reviewed the CDC contraindications to vaccination—specifically the COVID-19 vaccine—and that there are no health-related reasons or conditions that preclude my participation.

The U.S. Food and Drug Administration (FDA) requires that drugs used in the United States be both safe and effective. The COVID-19 vaccine has been previously FDA-approved for all ages over 6 months, including during pregnancy. Recent restrictions have removed this blanket coverage without supportive changes in safety data.

By requesting this prescription, I certify that it is reasonable to state that I have at least one risk factor for a severe course of COVID-19. Risk factors for more severe COVID-related illness may include, but are not limited to:

• Physical inactivity
• Frailty
• Previous smoking or tobacco exposure
• Solid Organ or blood disease
• Being Overweight
• Use of medications that affect the immune system
• Genetic or metabolic disease
• Any disability, including learning disabilities such as ADHD
• Mental health condition, including depression or substance dependency 

The details of this treatment, including anticipated benefits, material risks, and disadvantages, have been explained to me in terms I understand.

Alternative treatments, prescriptions, and therapies, along with their benefits, material risks, and disadvantages, have also been explained to me in terms I understand.

I understand and accept that information regarding the most likely material risks and complications of using a COVID-19 vaccine has been provided. These may include, but are not limited to:

1. Sore arm
2. Flu-like symptoms
3. Redness or irritation at the injection site
4. Rare events such as an allergic or atypical immune response affecting the brain, blood, lungs, or heart  

I have informed the healthcare provider of all my known allergies.

I understand that no outcome can be guaranteed in any medical treatment. While vaccination is the lowest-risk option for most people’s health, I recognize that no choice is without the possibility of a negative outcome. I accept a small risk of injury for this intervention.

The healthcare provider has answered all of my questions regarding this treatment to my satisfaction.

I certify that I have read and understood this medical agreement, including vaccine information on risks and benefits, and that all blanks were filled in prior to my signature.

In consideration of my registration and participation in this service, I hereby initial and agree to the following:

(A) I WAIVE, RELEASE, AND DISCHARGE the following entities or persons: Britni Fabacher Hebert, MD APMC, and/or their directors, officers, employees, volunteers, representatives, and agents, as well as the activity sponsors and volunteers (collectively, the "Britni Fabacher Hebert, MD APMC Parties"), from any and all liability, including but not limited to liability arising from the negligence or fault of the released persons or entities, for my disability, personal injury, death, property damage, property theft, or any other actions or events that may occur to me in connection with my participation in this activity.

(B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the Britni Fabacher Hebert, MD APMC Parties for any and all liabilities or claims made as a result of my participation in this activity, whether caused by the negligence of the releasees or otherwise.

I acknowledge that the Britni Fabacher Hebert, MD APMC Parties are not responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

This Medical Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT, AND I SIGN IT OF MY OWN FREE WILL.