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.
