Please print, initial and sign where indicated and return to [email protected].
INFORMED CONSENT FOR IN-PERSON TRAININGS DURING THE COVID-19 PUBLIC HEALTH CRISIS
This document contains important information about our decision (yours and Cynthia Schwartzberg) to participate in an in-person training during the COVID-19 public health crisis. Our decision is based in part on recommendations by the Center for Disease Control (CDC), but other factors may be considered. Some of these include but are not limited to whether we and our families have been vaccinated, our health or the health of those we are in close contact with, and risk of exposure outside of this event.
Please read this carefully and let us know if you have any questions. When you sign this document, it will be an official agreement between us.
Decision to Meet Face-to-Face
We have agreed to meet in person for the Brainspotting Intensive in Costa Rica January 23-28, 2024.
Risks of Opting for In-Person Services
You understand that by coming to the training in person, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service.
Your Responsibility to Minimize Your Exposure
To attend the training in person, you agree to take certain precautions which will help keep everyone (you, us, other registrants, assistants and our families safer) from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in you participating in the training by zoom instead. Initial each to indicate that you understand and agree to these actions:
- You will attend the training in person only if you are symptom free. ___
● You will only attend the training if you have been free from a fever for a minimum of 10 days prior to our training. ___ - You will wash your hands or use alcohol-based hand sanitizer when you enter the building. ___
- You will take steps each day/evening to minimize your exposure to COVID. ___
● If a resident of your home or in your hotel room tests positive for the infection, you will immediately let us know, and transfer to a different training. ___
We may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
Our Commitment to Minimize Exposure
Cynthia Schwartzberg and assistants have taken steps to reduce the risk of spreading the coronavirus within our training venue. Please let us know if you have questions about these efforts.
If You or I Are Sick
You understand that we are committed to keeping everybody in the training safe from the spread of this virus. If you show up for the training and we believe that you have a fever or other symptoms, or believe you have been exposed, we will ask and require you to leave the building immediately and transfer to a different training.
If Cynthia Schwartzberg or the assistants test positive for the coronavirus, we will notify you so that you can take appropriate precautions.
Informed Consent
Your signature below shows that you agree to these terms and conditions.
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Registrant Date
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Cynthia Schwartzberg, LCSW for Cynthasis, Inc. Date