Full Name
    (Legal Name - Must Match Driver's License)




    Signature (must be legible and match name above)
    "My signature below confirms I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities recommend practicing social distancing and other measures due to COVID19. I further acknowledge that LaSorsa and Associates has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that LaSorsa and Associates can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to staff, and other attendees, hotel guests, etc. I voluntarily seek services provided by LaSorsa and Associates and acknowledge that I may be increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending.
    I attest that:
    * I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
    * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
    * I have not been diagnosed with Coronavirus/Covid-19 and/or not yet cleared as non-contagious by state or local public health authorities.
    * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
    I hereby release and agree to hold LaSorsa and Associates harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of staff, or that may otherwise arise in any way in connection with any services received from LaSorsa and Associates. I understand that this release discharges LaSorsa and Associates from any liability or claim that I, my heirs, or any personal representatives may have against the firm with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from LaSorsa and Associates. This liability waiver and release extends to LaSorsa and Associates together with all owners, partners, and employees."