LEAPS AND BOUNDS THERAPY HEALTH AND SAFETY CONSENT FORM, WAIVER OF LIABILITY AND INDEMNIFICATION:

Leaps and Bounds Therapy has approved in home therapy for our families and clients who prefer services in the home. Telehealth services are still an option for those who prefer it. We are taking COVID-19 seriously and want to promote the health and well-being for your child, family and our team as we set forth to offer these sessions. If interested in having in home physical therapy sessions, please read through and sign Leaps and Bounds Therapy Health and Safety Consent Form and waiver of liability and indemnification before setting up this appointment with your provider.
Name
(the patient name), will receive Physical Therapy from Leaps and Bounds Therapy during the COVID-19 pandemic.

I (We) understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infections secretions from someone with COVID-19. I (We) understand that the child (client) is considered non-vaccinated and can still contract COVID-19 I (We) understand that the symptoms listed below are representative of COVID-19 • Fever • Dry Cough • Shortness of breath or difficulty breathing • Runny nose • chills and muscle pain • vomiting, diarrhea • sore throat • new loss of taste or smell Revised December, 2021 By signing below: I (We) confirm that our child, and anyone in our home, do not display or currently have any of the symptoms that are representative of COVID-19, which are outlined above. (If someone does display these symptoms, I (We) are aware we can take part in therapy via teletherapy or phone consultations for a 14- day period and until having a negative COVID-19 test). I (We) understand the natural risk of infection by coming into close contact with someone with COVID19. With that understanding, I (We) understand that my physical therapist will maintain a good distance from me and my child when able but there will be times that they need to be close to my child in order to ensure safety and/or to support their body for successful completion of task. I (We) understand that therapy will continue to strive to focus on the parent-coaching model. I (We) understand that physical therapy via telehealth continues to be an option and is highly encouraged if in person therapy is not an option. I (We) understand that I will need to immediately notify the provider of the following: a) someone in the home tested positive for COVID 19 OR is experiencing symptoms. b) If my child/family has been in close contact (within six feet for greater than 15 mins) with someone who tested positive for COVID-19 with 10 days. I (We) understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. If we have travelled outside Illinois in the last 14 days, I (We) will discuss this with our therapist. If the therapist or family prefers, we will discuss options for live video visits (teletherapy) to be given for therapy during a 14 -day period upon your return. I (We) understand that although there are no guarantees in regard to the possibility of contracting COVID-19, my therapist will be following safety protocols as to best protect myself and the staff during treatment. My therapist will be wearing a mask, washing hands and sanitizing frequently, and family members present over the age of 2 will wear a mask while in the same room as the therapist. I (We) agree that I am personally responsible for my safety and actions while interacting with the therapists/providers of Leaps and Bounds Therapy, I agree to comply with all Leaps and Bounds Therapy policies and rules, including but not limited to all Leaps and Bounds Therapy policies, guidelines, signage, and instructions. Because Leaps and Bounds Therapy is open for other individuals as well, I recognize that I am at higher risk of contracting COVID-19. With full awareness and appreciation of the risks Revised December, 2021 involved, I, for myself and on behalf of my family, spouse, estate, heirs, executors, administrators, assigns, and personal representatives, hereby forever release, waive, discharge, and covenant not to sue Leaps and Bounds Therapy, its officers, agents, independent contractors, affiliates, employees, successors, and assigns (collectively the “Released Parties”) from any and all liability, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, or injury, including death, that may be sustained by me related to COVID-19 whether caused by the negligence of the Released Parties, any third-party working with Leaps and Bounds Therapy or otherwise, while participating in any activity with Leaps and Bounds Therapy and/or while using any Leaps and Bounds Therapy tools, equipment, or materials. I (We) agree to indemnify, defend, and hold harmless the Released Parties from and against any and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney fees) arising either directly or indirectly from or related to any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my use of the Leaps and Bounds Therapy tools, equipment, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19. By signing below I acknowledge and represent that I have read the foregoing Waiver of Liability, understand it and sign it voluntarily as my own free act and deed, including without limitation the Release of Liability and Indemnification requirements contained in this document; I am sufficiently informed about the risks involved to decide whether to sign this document; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this document for full, adequate, and complete consideration fully intending for myself and my named child(ren) to be bound by the same. I agree that this Wavier of Liability shall be governed by and construed in accordance with Illinois law, and that if any of the provisions hereof are found to be unenforceable, the remainder shall be enforced as fully as possible and the unenforceable provision(s) shall be deemed modified to the limited extent required to permit enforcement of the Waiver of Liability as a whole. This waiver remains in effect until the State of Illinois limits all COVID-19 related mandates.

LEAPS AND BOUNDS THERAPY HEALTH AND SAFETY CONSENT FORM, WAIVER OF LIABILITY AND INDEMNIFICATION:

I state that I have read, understand, and agree to the above Leaps and Bounds Therapy Health and Safety Consent Form, Waiver of Liability and Indemnification:
Child's Name(Required)
Parent/Guardian's Signature(Required)
By completing this field and submitting this form I accept responsibility of signature and agree to the above statements.
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