COVID-19 VACCINE
ASSUMPTION OF RISK, WAIVER, AND RELEASE
For use by Students that are not vaccinated for COVID-19
(Please read carefully before signing)
I, _______________________ (Name of Parent), as parent/legal guardian of ______________________ (Name of
Student), I knowingly and voluntarily covenant and agree as follows:
I request an exemption from the COVID-19 Vaccine Mandate based on the following and have completed the
accompanying exemption form (check one)
_____ Medical Exemption
_____ Non-Medical Exemption
_____ Age-Based Exemption
Regardless of the steps taken by the _________________ School to reduce the risks associated with the
COVID-19 pandemic, I am fully aware that there are a number of risks associated with my child accessing and using the
________________Property during the COVID-19 pandemic, including, but not limited to, being exposed to and contracting COVID-19
from individuals, surfaces, and airborne particles. I further understand that no actions by _____________________will guarantee that I will
not contract COVID-19.
On behalf of my child, and his/her heirs, successors, and assigns, by accessing and using the Property, I
knowingly and freely assume all risks, both known and unknown, related to COVID-19, including all illnesses, injuries,
damages or death arising therefrom.
On behalf of my child, and his/her heirs, successors and assigns, voluntarily agree to release, waive, discharge,
hold harmless, defend and indemnify the Santa Fe Indian School, its staff, board, officers, affiliates, insurers, successors,
and agents (collectively, the “Indemnified”) from any and all claims, demands, torts, contracts, obligations, suits, actions,
causes of action, or damages (“Losses”) arising from or related to COVID-19 connected in any way with my child’s access
or use of the SFIS Property, including, but not limited to, claims based on the alleged negligence of any Indemnified or
any other person. I further promise not to sue SFIS or any Indemnified for any illness, injury, death, or other Losses
arising out of or related to COVID-19 and agree to indemnify and hold them harmless from any and all Losses resulting
therefrom. I have read this COVID-19 Assumption of Risk, Waiver, and Release carefully and understand its terms.
_______ I understand and agree that because my child is not fully vaccinated that he/she will be held to
(initials) restrictions established by the Centers for Disease Control (CDC) Guidance and the Santa Fe Indian School
Guidance.
I executed this Agreement knowingly, freely, and voluntarily without any inducement, duress or coercion, intending to
be legally bound.
________________________________ ________________
Printed Name (Parent/Legal Guardian) Date:
________________________________
Signature
________________________________ ________________
Printed Name (Student) Date:
________________________________
Signature
