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WAIVER OF LIABILITY RELATING TO REFUSAL TO VACCINATE

I acknowledge the contagious nature of the COVID-19 and that the government and many other public
health authorities still recommend having everyone get vaccinated and continue practicing health and
safety protocols. I further acknowledge that [COMPANY NAME] has put in place preventative measures
to reduce the spread of the COVID-19 in the workplace including providing free vaccines against COVID-
19 for all of its employees.

Nevertheless, I have decided to decline to get vaccinated for personal reasons. I know that failure to
follow the recommendations about vaccination may endanger my health or life and others that I might
come in contact with.

I hereby release and waive my right to bring suit against [COMPANY NAME] and its owners, officers,
directors, managers, officials, trustees, agents, employees, or other representatives in connection with
exposure, infection, and/or spread of COVID-19 by refusing to get vaccinated and that such action may
result for risk of exposure or infection, illness, permanent disability, and death. I understand that this
waiver means I give up my right to bring any claims including for illness, death, or any other loss,
including but not limited to claims of negligence and give up any claim I may have to seek damages,
whether known or unknown, foreseen or unforeseen.

I acknowledge that I have read this document in its entirety and fully understand it.

________________________
Printed Name and Signature
Date: ____________