(To be filled by Registration Office)

Name…………………………………………….
Temperature at entry………………………..
Oxygen saturation level at entry…………..

COVID-19 LIABILITY RELEASE & WAIVER

In consideration of the Vipassana Meditation Centre, Dhamma Karunika, Karnal

(in short ‘the Centre’)’s acceptance of my application for the Vipassana Course on
the terms and conditions laid down by the Centre, I, Mr/Mrs/
Ms………………………………………………………………………………………………………
s/o, d/o, w/o……………………………………………………..aged about……….years
hereby declare and undertake as under:

That I am aware of the existence of risk involved in my participation in this

residential course that may cause injury or illness such as Covid-19 that
may necessitate intensive and expensive medical treatment.

That I have not experienced any symptoms of fever, fatigue, difficulty in

breathing, dry cough or manifestation of any other symptoms relating to
Covid-19 or any other communicable disease in the last 14 days.

That neither I nor any member(s) of my family have been diagnosed to be

infected of Covid-19 virus in the last 30-days; that neither I nor any
member(s) of my family have travelled internationally in last 30-days;

Following the above, I hereby further declare the following:-

I am fully and personally responsible for my own health, safety and actions
while and during my participation in the course and I recognise that I may
be in any case be at risk of contracting Covid-19.

With full knowledge of the risks involved, I hereby release, waive, discharge
the Centre, the Trust, the Teacher and other persons engaged with the
arrangements of the course and their successors and assigns from any and
all liabilities, claims, demands, actions and causes of action whatsoever,
directly or indirectly arising out of or related to any loss or damage, injury or
death, that may be sustained by me related to Covid-19 while participating
in any activity while in, on, or around the premises or while using the
facilities that may lead to unintentional exposure and harm due to
Covid-19.

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 I agree to indemnify, defend and hold harmless the Centre, the Trust and
other persons involved with the administration and management of this
course from and against any and all costs, expenses, damages, lawsuits,
and/or liabilities or claims arising whether directly or indirectly from or
related to any and all claims made by or against any of the released party
due to injury, loss or death from or related to Covid-19.

By signing below, I acknowledge that I have read the foregoing Liability Release &
Waiver and understand its contents; that I am ……….…years old and fully
competent to give my consent; that I have been sufficiently informed of the risks
involved and give my voluntary consent in signing this Liability Release & Waiver
on my own free will, act, deed and free from any inducement, coercion or
representation, with full intention to be bound by the same.

This waiver will remain in force until laws and mandates relevant to Covid-19 are
lifted.

Full Name……………………………………………… Signature…………………………….

Phone No……………………………………………… Date……………………………..

Address……………………………………………………………………………………………….

PLACE: DHAMMA KARUNIKA, KARNAL

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