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Informed Consent and Release

The 84 Movement’s In-Person Leadership Retreat 2022 

In-Person/Virtual: Friday, August 26 from 10am-4pm

I hereby agree and grant permission for my child to participate in The 84 Movement’s In-Person Leadership Retreat with Health Resources in Action taking place in-person on Friday, August 26, 2022. 

I am aware that a meal will be served to my child and I understand it is my responsibility to inform team leaders of any allergies my child has. I understand that by signing this waiver I am assuming for myself and for my child and their family including any parent guardian or estate all risks of injury and/or loss associated with the participation in the 84 Leadership Retreat.  In the event of illness or injury to my child, I give express consent to Health Resources in Action staff to order the administration of emergency medical care to him/her, if such action is advisable.  

COVID-19 Policy 

HRiA has developed workplace COVID-19 policies based on federal and state guidance that apply to its staff and programs. In alignment with these policies, the following guidelines have been established for The 84 Movement to ensure the safety and health of the HRiA and The 84 community.  

Vaccination: SLT and MSA are required to be fully vaccinated for COVID-19 and show proof of vaccination before the start of in-person programming. To confirm vaccination status for our records, The 84 SLT, MSA, and staff will show their vaccination card one time to HRiA staff. We will not keep a copy of the vaccination card on file. 

To be considered up to date with Covid-19 vaccination, Pfizer-BioNTech and Moderna recipients should receive three doses of a vaccine, and J&J recipients should receive two doses, preferably with the second being an mRNA vaccine. 

Masking: The 84 SLT and MSA must wear a mask for the duration of programming while at the 2 Boylston office and maintain social distance when possible.  

Presence of Symptoms: The 84 SLT and MSA who feel sick or have any cold, flu, or COVID-19 symptoms (particularly cough, fever, sore throat, loss of taste or smell, runny nose, fatigue) must stay home.  

COVID-19 Infection: If anyone develops symptoms consistent with COVID-19 and/or tests positive for COVID-19 after the in-person meeting, they must notify The 84 staff immediately and follow the advice of their healthcare provider.  

I am aware that I may contact the personal cell phones of The 84 staff.  

Contact numbers:  

By entering into this release and granting permission as stated herein, I am releasing Health Resources in Action and their respective trustees, officers, directors, agents, students and/or employees; and all individuals, corporations, partnerships and organizations affiliated with The 84 Movement’s In-Person Leadership Retreat 2022, and any of their respective officers, directors, agents and/or employees, from and against all liability, loss, damage, cost claims and/or causes of action arising out of or related to my child’s participation in this leadership team event. 

Informed Consent and Release Form

I have read the Informed Consent and Release Form and understand the terms.(Required)
I sign it voluntarily and with full knowledge of its significance.(Required)
Youth Name(Required)
Parent/Guardian/Caregiver's Name(Required)
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