Parent/Guardian In-Person Pair Session
                              COVID-19 Policy Form
                            2021 — 22 Program Year

The health and safety of our community is of utmost importance, especially while the world navigates the COVID-19 pandemic. 

While more people are being vaccinated and the country is opening up, we're allowing pair sessions to safely take place in person.

Please read our policy in detail, commit to following it and provide proof of your child/minor's vaccination or vaccination exemption below.

Your Information

hereby certify that I am a parent/guardian of:                    


Child/Minor's Information



In-Person Pair Session COVID-19 Policy
We strongly recommend that pairs adhere to the following COVID-19 safety guidelines when meeting in person:
  • Vaccination: We require both mentees and mentors to be vaccinated if they are going to have in-person pair session(s), unless one or more members of the pair has an approved exemption.
  • COVID-19 negative test: If your child/minor is receiving an exemption to being vaccinated against COVID-19, your child/minor must show proof of a negative COVID rapid or PCR test within 48 hours of their scheduled in-person pair session. They must send this proof to your Staff Pod Lead.
  • Masks: You child/minor must wear a mask at all times if they are meeting inside. If they are outside, masks are optional.
  • Social distancing: When possible, practice social distancing of six feet apart, regardless of whether the pair is meeting outside or inside.
  • Hand sanitizing/washing: Your child/minor must sanitize and/or wash their hands thoroughly before, during and after their in-person pair session(s).
  • COVID-19 contraction: Your child/minor is required to inform Girls Write Now (GWN) immediately if they contract COVID-19, and they must cooperate with GWN regarding their participation in the GWN Program in light of this information

Moreover, as part of this policy:

  • If you believe you have been exposed to COVID-19: Under no circumstances is your child/minor permitted to meet in-person with any member of the Girls Write Now community, including their mentee/mentor.
  • If your child/minor's mentor is receiving an exemption for the COVID-19 vaccine: Your child/minor's mentor reserves the right to require that all pair sessions take place virtually. This is in an effort to keep everyone safe, healthy and comfortable.
  • The Girls Write Now office remains closed until further notice. As a result, pair sessions cannot take place at our offices. For a list of recommended places to have pair sessions, please reference our In-Person Pair Session Conversation Guide.

hereby commit to ensuring my child/minor follows GWN's COVID-19 Pair Session policy as outlined in this form. I commit to encouraging my child/minor to wear a mask at all times, practice safe social distancing, hand sanitizing methods and informing GWN if they contract COVID-19, as outlined in Girls Write Now's COVID-19 Pair Session policy. I further commit to ensuring my child/minor cancels in-person pair sessions if they believe they have been exposed to COVID-19. I understand that it is my child/minor's responsibility to follow these guidelines for the safety of my child/minor, their mentor and the GWN community.
Submitting this form does NOT mean you are approved to have in-person pair sessions. 

A GWN staff member will review the proof of vaccination and/or request for a vaccination exemption and will approve or deny your request for your child/minor to have in-person pair sessions within 7 days from when we receive this form. Both members of the pair (the mentee and mentor) must be approved for in-person pair sessions before you can meet in person. If your mentee/mentor does not submit their request on the same day as you, this may slow down the approval process.

Disclaimer: Girl Write Now's COVID-19 Pair Session Policy, as outlined above, is subject to change at any time, with little to no notice. We are constantly monitoring new variants and the CDC/local government's recommendations and adjusting accordingly.
Medical Vaccination Exemption
Girls Write Now requires one of the below in order to request a medical exemption for the COVID-19 vaccine:

  • A completed medical exemption form from a licensed physician, such as: NYS Department of Health Student Exemption Form or a form supplied by your health care provider
  • A written letter signed by a licensed physician explaining why your child/minor is unable to receive the COVID-19 vaccine


hereby certify that my child/minor's medical exemption document has not been forged or altered in any way. By submitting this documentation, I am legally bound to this document being accurate and in truth of my child/minor's current medical status. 
Religious Vaccination Exemption
Girls Write Now will grant religious exemptions for the COVID-19 vaccination for those who have:
  • A sincere commitment to a religious belief that inhibits them from receiving the COVID-19 vaccine

  • Have not received other vaccines due to their religious beliefs and do not take certain medications

Girls Write Now will not grant religious exemptions for those who are not receiving the vaccination for personal beliefs, if those beliefs are not due to their religion.










hereby certify that the above answers reflect my child/minor's religious beliefs and their sincerity of practicing these beliefs, are accurate and that I am legally bound to these answers being in truth.
Proof of Vaccination


Please note: if your child/minor received the Pfizer or Moderna vaccine, Girls Write Now requires them to have received TWO doses of the vaccine. They must have received the second vaccine dose within 45 days of receiving the first dose.




Please note: if your child/minor received their second dose six months ago or more for the Pfizer or Moderna vaccine, or two months ago or more for the Johnson & Johnson vaccine, Girls Write Now requires them to receive a vaccine booster before they can meet in-person for pair session(s).


hereby certify that my child/minor's vaccination card has not been forged or altered in any way. By submitting my child/minor's proof of vaccination, I am legally bound to this proof being accurate and in truth of my child/minor's current vaccination status. 
Release Form

understand that the novel coronavirus, COVID-19, has been declared a pandemic by the World Health Organization, and that COVID-19 is reported to be extremely contagious. The state of medical knowledge is evolving, but COVID-19 is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and in the air. People reportedly can be infected with COVID-19 and show no symptoms and therefore spread the disease. As of today, the exact methods of spread and contraction are unknown, and there is no known cure. I understand that during the COVID-19 pandemic, federal, local and state governments have been and will continue to issue COVID-19-related orders concerning reopening, social distancing and quarantine. My child will cooperate with such orders, and any COVID-19 related rules set forth by GWN in connection with the GWN Program. I agree to inform GWN immediately if my child contracts COVID-19, and will cooperate with GWN regarding my child’s participation in the GWN Program in light of this information. I also understand that GWN cannot prevent my child from becoming exposed to, contracting, or spreading COVID-19 while participating in the GWN Program. It is not possible to prevent against the presence of COVID-19.

Therefore, I understand that my child/minor may be exposing themself to and/or increasing their risk of contracting or spreading COVID-19 by having in-person pair sessions.

ASSUMPTION OF RISK: I hereby give my child permission to accept the risk of contracting COVID-19 while participating in the GWN Program. The GWN Program provides services that are of such value to my child that I accept the risk of my child being exposed to, contracting, and/or spreading COVID-19 in order to have in-person pair sessions.

WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right and my child’s right to bring suit against GWN and its officers, directors, employees, agents, volunteers (including mentors) or other representative in connection with exposure, infection and/or spread of COVID-19 in connection with my child’s participation in the GWN Program. I understand that this waiver means I give up my right and my child’s right to bring any and all claims including but not limited to personal injuries, bodily injury, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any and all claim either I or my child may have to seek damages, whether known or unknown, foreseen or unforeseen.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY PERMIT MY CHILD TO ASSUME THE RISK AND WAIVE MY RIGHTS AND MY CHILD’S RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE. I HAVE LEGAL RIGHT TO CONSENT TO AND, BY SIGNING BELOW, I HEREBY CONSENT TO THE TERMS AND CONDITIONS OF THIS RELEASE.

COVID-19 Release Form E-Signature
I HAVE READ AND UNDERSTOOD THE TERMS OF THE COVID-19 RELEASE ABOVE, AM OVER THE AGE OF 18 YEARS OLD, AND AGREE TO ABIDE BY ITS TERMS AS OF TODAY'S DATE SET FORTH BELOW.

PLEASE NOTE: After you successfully e-sign this form, you will receive an email to the email address provided below. Please verify your signature via that email as soon as possible.