Name *

First Name

Last Name

Assumption of Risk *

Symptoms of COVID-19 include: -Fever -Fatigue -Dry Cough -Difficulty Breathing I agree to the following:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 14 days.

I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 14 days.

I understand that Amanda Anderson Photography and Amanda Anderson personally, cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

Date *

MM

DD

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