Pre-service indemnification

(808) 364 - 9715
info@ponohome.com

COVID-19

Pono Home values your health! Please fill out the following form, so we can schedule you for a time that helps ensure safety comes first!
Have you or others in your household had close contact with a person with confirmed or suspected COVID-19?
- Yes
- No
Have you or others in your home traveled outside of the island in the last 14 days?
- Yes
- No
Are you or others in your home currently ill or experienced any of the following COVID-19 symptoms (i.e. fever, cough, shortness of breath, chills, repeated shaking with chills, muscle or body aches, headache, fatigue, sore throat, congestion or runny nose, nausea/vomiting, diarrhea, new loss of taste or smell)?
- Yes
- No
Are there any individuals 65 years or older at the residence?
- Yes
- No
Are there any individuals with weakened immune systems or chronic medical conditions (i.e. heart disease, lung disease, diabetes, kidney disease, asthma, smoking)?
- Yes
- No
Where do you live?
- Molokai
- Oahu
- Big Island
- Maui
- Lanai
Your email*
Phone
Name
First Last
Indemnification: I, the undersigned, hereby unconditionally and irrevocably release, waive and forever discharge Pono Home, Inc. and its affiliates, directors, owners, members, shareholders, and employees from any and all causes of action, claims and damages, including attorneys’ fees, whether known or unknown, foreseen or unforeseen, presently asserted or otherwise arising through the date of his or her signing of this Indemnification clause (a legal and binding Waiver and Release Agreement), concerning Pono Home services including but not limited to home energy conservation education and energy efficiency audit and retrofit services. This release includes, but is not limited to any claim arising under any state or local laws, ordinances or regulations (including, but not limited to, any state or local laws, ordinances or regulations requiring that advance notice be given of liability claims). I also declare this to be a legal and binding digital signature and waive any right to require paper copies or printed signatures. In the case of any disagreements or challenges that arise, I agree to a) try to settle things amicably, lacking that, b) to be bound to a decision by a Judicial Arbitration and Mediation Services, Inc. (JAMS) arbitration process and waive any rights I have to seek out other legal processes, including any and all lawsuits. I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious and that it may be impossible to determine who has it and who doesn't, given the current limits of virus testing. I confirm that I am not presenting any symptoms including but not limited to fever, shortness of breath, dry cough, runny nose or sore throat. I verify that I have not traveled outside Hawaii for the last 14 days, and if I have, I have let the Pono Home service technician know. In the interest of public health, I agree to let Pono Home know immediately if I do later have symptoms and/or test positive for COVID-19.*
Sign below (if no text entry box appears below, just click in the space below and it'll give you a space to sign).
Use a slash like this: / in front and at the end of your name. For instance, Scott Cooney would sign this /Scott Cooney/