LIABILITY RELEASE AND WAIVER
1. I, the undersigned acknowledge that I wish to be vaccinated against COVID-19.
2. The benefits of receiving the Vaccination has been explained to me, or I have had the opportunity to research them for myself and I fully understand and appreciate the dangers, hazards, and risks that may arise from not being vaccinated. These dangers, hazards, and risks can result in impairment to my body, general health, well-being, and could include serious or even fatal results.
3. Knowing the dangers, hazards, and risks of not receiving the Vaccination, on behalf of myself, my family, spouse, heirs, and personal representative(s) (the “Releasors”), I agree to assume all the risks and responsibilities surrounding my failure to be vaccinated. On behalf of myself and the Releasors I hereby covenant not to sue East Norriton Pharmacy, or the West Norriton Township or its
trustees, officers, representatives, volunteers, and employees (“Releasees”), and I hereby release, waive, and forever discharge the Releasees from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature that I may have or that may hereafter accrue to me or a Releasor, arising out of, or related to, my failure to receive the Vaccination. It is my expressed intent that this Liability Release and Waiver shall bind me, the members of my family and spouse, if I am alive, and my estate, family, heirs, administrators, personal representatives, or assigns, if I am deceased, and shall be deemed as a legally binding release, waiver, discharge and covenant not to sue the Releasees. I have truthfully answered all the questions regarding my medical history that are listed above.
4. I voluntarily request and consent that a pharmacist employed by East Norriton Pharmacy administer to me the following vaccine(s) (“Vaccine”) I have had an opportunity to ask the East Norriton Pharmacy pharmacist any questions about the Vaccine or about information in the Vaccine Information Statement and my questions have been answered to my satisfaction.
5. I understand that there is a likelihood that I will experience an adverse reaction from the administration of the Vaccine. After careful consideration, I believe that the benefits of receiving the Vaccine outweigh the risks associated with receiving the Vaccine and I have decided to have the East Norriton Pharmacy pharmacist administer the Vaccine to me East Norriton Pharmacy, or the west norriton township shall not, at any time, or to any extent allowable by applicable law, be liable, responsible, or in any way be accountable for any loss, injury, death, or damage suffered or sustained by me or any other person at any time in connection with, or as a result of, the administration of the Vaccine to me by the East Norriton Pharmacy pharmacist.
6. I, for myself, my heirs, executors, personal representatives and assigns, hereby release East Norriton Pharmacy, or the West Norriton Township, its employees and contractors, specifically the administering pharmacist, its agents or representatives from any 4 and all claims arising out of, in connection with, or in any way related to my receipt of the Vaccine from East Norriton Pharmacy as allowed by applicable law.
7. If applicable by signing below, I certify that I am the vaccinated or the vaccinated’s patent/legal guardian.
8. I hereby agree to abide by all rules, instructions, policies and procedures imposed by the Releasee relating to the use of the facilities or property.
9. I certify I am signing this of my own free will and accord, voluntarily and without duress.
10. This entire document is to be construed as if written mutually by all parties and any commencement action shall be in Montgomery County Pennsylvania.
THIS IS A LEGAL AGREEMENT AND INCLUDES A RELEASE OF LEGAL RIGHTS. READ AND BE CERTAIN YOU UNDERSTAND IT BEFORE SIGNING.