ASSUMPTION OF RISK AND RELEASE FORM THIS IS A RELEASE OF LEGAL RIGHTS – READ AND UNDERSTAND BEFORE SIGNING
Name of employee : __________________________________________________
Date of Birth: _________________________
(If under 18 years of age, a parent or legal guardian must also read and sign this form.)
Organization: THE_ moRON _ Mentoring SENIOR Program
I hereby agree as follows:
1. Risks of Participation.
I fully recognize that there may be risks to which I may be exposed by participating in thIS project. I understand that the_mo_ron and its
governing board, officers, employees, and agents (collectively the “COMPANY”) does require me to participate in the Program, but I
want to do so, despite the possible risks and despite this Release. I therefore agree to assume and take on myself all of the risks and
responsibilities in any way associated with the service project. I understand that I am responsible for wearing proper attire for the activities and weather.
2. Health & Safety.
I understand and agree that the COMPANY does not have medical personnel available at the service site which is the location for my
participation in the service project. Furthermore, I understand that the nearest medical facility could be up to thirty minutes from the
site. I understand and agree that the COMPANY is granted permission to authorize emergency medical treatment, if necessary, and
that such action by the COMPANY shall be subject to the terms of this Agreement. I understand and agree that the COMPANY
assumes no responsibility for any injury, damage or cost which might arise out of or in connection with such authorized emergency
medical treatment.
I have consulted with a medical doctor with regard to my personal medical needs. There are no health-related reasons or problems that preclude or restrict my participation in this service project. I am aware that I need to inform the COMPANY of any medical conditions which may affect my participation in the program and I agree that while participating in this project, I am responsible for taking any prescription medications as directed by my physician.
The COMPANY provides excess accident insurance covering medical expenses for EMPLOYEE’S while on travel status, and for doing
work for the COMPANY. The coverage is automatic, has specific limits and exclusions, and is in excess of any other applicable insurance.
I understand that neither …
I understand that I am expected to carry liability insurance coverage.
I agree that I have elected to provide my transportation to or have elected to pool with a participant.
3. Standards of Conduct
I will comply with the rules, standards and instructions for behavior, including, as well as the agency’s standards of conduct.
I understand that I am permitted to consume alcohol, possess/use illegal substances or weapons, or engage in sexual/illicit behavior while participating in activities.
I understand that violation of a policy will result in my further sanctioning .
I waive and release all claims against the COMPANY that arise at the time when I am not under the direct supervision or that are caused by my failure to remain under such supervision or to comply with such rules, standards, and instructions.
4. Assumption of Risk, Covenant Not To Sue, and Release of Claims. Knowing the risks described above, and in consideration of being permitted to participate in the Program,
I agree, on behalf of my family, heirs, and personal representative(s), to assume all the risks and responsibilities surrounding my participation . To the maximum extend permitted by law, I release, indemnify, and covenant not to sue from and against any present or future claim, loss or liability for injury to person or property which I may suffer, or for which I may be liable to any other person, during my participation (including periods in transit).
I have carefully read this Release Form before signing it. No representations, statements, or inducements, oral or written, apart from
the foregoing written statement, have been made. This agreement shall be governed by the laws of the state , which shall be the forum
for any lawsuits filed under or incident to this agreement or to the Program.
x_____________________________ _______________
Signature of Participant Date
Emergency Contact Information
Name : __________________________________ Telephone: ____________________
Address: ________________________________________________ Email: ________________________
Please list any environmental allergies here:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any other medical conditions of which we should be aware here:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
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