[NAME OF ENTITY (“Company”)]

CONSENT FORM
(Must be completed in full by the Employee or a family member of the Employee)

Employee Name:
Employee Id:
Date:
Person Administering Consent:
Family Member (Spouse/ Children/ Parent of Employee):

I, Mr / Mrs / Miss …………………………………………, aged ________ years, resident of

____________, working in the capacity of _______________ with the Company OR __________ (family
member) of the Employee identified above, do hereby give consent to receive/administer for myself the
COVID – 19 vaccine, which is being facilitated by the Company as a welfare measure, free of cost, for
the Employee and his/her family members.

I am voluntarily availing the Covid-19 vaccination out of my own free will, consent and risk and this is
not being administered under duress, coercion or as an employment condition.

I have no past/ present medical ailment/condition/pregnancy that will interfere/ restrict /make me non-
eligible for availing the Covid -19 vaccination. I assume full responsibility for taking the vaccination and
for any reactions/ side effects/ contingency/consequences whatsoever arising from administering the
vaccination.

I hereby affirm that I understand the purpose and potential benefits availing the COVID-19 vaccination
and that no representation/guarantee has been made to me by the Company in relation to the Covid -19
vaccine to act as a cure/precaution from Covid-19.

I understand that the Company makes no warranties, express or implied, including but not limited to,
implied warranties of merchantability or fitness for a particular purpose regarding the vaccine or its
effectiveness.

I, for myself and my heirs, administrators, trustees, executors, assigns and successors in interest do hereby
agree to release and hold harmless the Company, its subsidiaries, divisions, affiliates, successors, assigns,
officers, trustees, employees, volunteers and agents from and against any and all contingencies,
consequences, demands, damages, losses, costs, expenses, obligations, liabilities, claims, actions and
cause of action (whether any of which is groundless or otherwise) of any nature whatsoever (including,
without limitation, reasonable attorney’s fees and court costs) by reason of or resulting, in any way, from
any and all acts, accidents, events, occurrences, omissions and the like related to, or arising out of,
directly or indirectly, my receiving this COVID-19 vaccine.

Signature Signature
Employee/Family Member Company Authorized Representative
Date Place