Chevy Chase, MD
In-Person Music Instruction Waiver Form
Studio Release Form (Covid-19)
We are requiring that all private lesson students/families/teachers requesting or resuming in person lessons sign this release.
Confirmation of Studio Relationship
Please select one.
I'm a legal guardian of an enrolled student(s)
I'm a teacher
I'm an adult student
Parent, Teacher or Adult Student Name
Please list all minor students in your household.
By my signature, I acknowledge that I have read and agree to all the below terms on my own behalf and that of all listed minor children (under 18) of whom I am legal parent/guardian.
COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state and local governments and agencies recommend social distancing and compliance with safety protocols to mitigate the risk of contracting the virus.
SAFETY PROTOCOLS: The Parent acknowledges and agrees that the student has been instructed by the Parent (for minors) to strictly comply with all safety protocols implemented by the Studio to reduce the risk of contracting or spreading the virus while the student is receiving in-person music instruction. Adult students and teachers also agree to abide by all safety protocols.
Safety protocols include, but are not limited to, wearing a face mask or covering at all times, observing physical distancing, frequent hand-washing and/or the use of hand sanitizer, and any other safety and health protocols the Studio may implement. If any student, teacher, family member or household member experience symptoms including fever, cough, chills, or extreme fatigue 48 hours prior to a scheduled lesson time, notification to the other party is required and the lesson will be rescheduled or completed virtually.
ASSUMPTION OF THE RISK: Despite the safety protocols and procedures implemented by the Studio to mitigate the transmission of COVID-19, the Parent/Teacher/Adult understands and acknowledges that there are
inherent risks that the Parent, Teacher or the Student may become infected with COVID-19 due to in-person music instruction at the student's home. These risks include, but are not limited to, the following: exposure to COVID-19, becoming infected with COVID-19, or becoming a symptomatic or asymptomatic carrier of the virus. It is possible that the Parent/Teacher/Student are already asymptomatic carriers of the virus and that they may infect others as a result of in-person music instruction. The Parent/Teacher/Adult understands that his, her or the Student’s possible exposure to COVID-19 may result in Parent, Teacher or Student spreading the infection to other family members or other persons. The Parent/Teacher/Adult Student recognizes that any person who receives a positive diagnosis of COVID-19, including the Student or other family member, may encounter extended quarantine/self-isolation, additional tests, medical care, hospitalization, other potential complications, and the risk of death. Parent/Teacher/Adult Student hereby acknowledges and assumes the risk of the Parent, Teacher or the Student becoming infected with COVID-19 as a result of Student’s receiving in-person music instruction.
I acknowledge I voluntarily assume the risk that we may be exposed to COVID-19 by choosing to have in-person lessons. I voluntarily agree to assume all risks and accept sole responsibility for illness and any expense and consequences we may experience by having in-person lessons with Soulfege Music Studio.
I hereby release, covenant not to sue, discharge, and hold harmless Soulfege Music Studio, its teachers, staff and owners, from the Claims, including all liabilities, actions, damages, costs or expenses of any kind arising.
Parent/Teacher/Adult Student Signature
Electronic Signature * The electronic signature above and their related fields are treated by Soulfege Music Studio like a physical handwritten signature on a paper form.
Chevy Chase, MD
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