MINOR VOLUNTARY
PARTICIPATION IN
MEDICAL & FIRE RESPONSE
&
ASSUMPTION OF RISK,
WITH
______________________________,
[Insert Correct Rural/Metro Legal Entity] (hereinafter referred to as
“Rural/Metro”) provides medical and/or fire emergency response services and all
activities related thereto (hereinafter referred to as “Response
Services”). I,
______________________________, [Print Name of Participant] (hereinafter
referred to as “Participant”), living at
_________________________________________________ [Insert Full Address]
desire to participant in, observe and/or otherwise take part in Response
Services to further my education, clinical experience and/or response
experience. I ACKNOWLEDGE THAT MY
PARTICIPATION IN THE RESPONSE SERVICES IS STRICTLY AS AN OBSERVER AND I FURTHER
ACKNOWLEDGE THAT I WILL NEITHER BE PERMITTED TO NOR WILL I RENDER ANY PATIENT
CARE.
My Parent or Legal Guardian,
__________________________ [Print Name of Parent or Legal Guardian] (hereinafter
referred to as “Parent/Guardian”) living at
___________________________________ [Insert
Full Address] consents to my participation in, observation of and/or
otherwise partaking in Response Services.
_____
INITIALS OF PARENT/LEGAL GUARDIAN
In
consideration of Rural/Metro’s consent to allow me to participate in its
inherently dangerous and risky activity of Response Services, I hereby
knowingly, freely and voluntarily agree as follows and Parent/Guardian,
knowingly, freely and voluntarily CONSENTS and AGREES as follows:
I,
as Parent/Guardian, represent to Rural/Metro that I am legally competent and age eighteen or older and my driver’s license
number is _________________, for the State of ______________ which states my
birth date as _______________. I
represent to Rural/Metro that I am Participant’s parent or legal guardian and
have the authority to give this legal consent and enter into this Agreement.
_____
INITIALS OF PARENT/LEGAL GUARDIAN
We, as Participant and Parent/Guardian, understand that each situation
that Rural/Metro responds to is based on incomplete and limited information
provided often under extreme and emergency conditions and which may or may not
be ultimately accurate. Moreover, we
understand that each situation will contain unforeseen and unknown hazards,
dangers and risks to me and to Rural/Metro. Rural/Metro’s Response
Services is based upon whatever current information is available,
at the time of the Response Services are provided so we expressly understand
and agree that Rural/Metro makes no representation or warranty expressed or
implied, written or oral regarding Response Services to me. ______ INITIALS OF PARENT/LEGAL
GUARDIAN
We,
as Participant and Parent/Guardian, understand that if Participant has an
infectious disease, or a medical condition which could be triggered by
participating in Response Services or if Participant is not physically capable
and mobile to move without assistance that Participant would endanger the
public and/or him or herself so that we represent that Participant does not
have any of the above conditions. ______ INITIALS OF PARENT/LEGAL
GUARDIAN
Given
the very nature of Response Services, participation in Response Services is
inherently dangerous and risky. We, as
Participant and Parent/Guardian, acknowledge that participating in
Response Services may result in, but is not limited to bodily injury, death,
emotional trauma, burns, extreme noise, extreme lights and/or exposure to
hazards like airborne or bloodborne pathogens, bacteria or other harmful
transmission to me. Exposure to an
airborne or bloodborne pathogen may result in the transmission of AIDS,
hepatitis, TB or other infectious diseases. ________ INITIALS OF PARENT/LEGAL
GUARDIAN
We
voluntarily and freely, with full understanding acknowledge that Participant
may be exposing him or her self to extreme danger, and we assume all
risks in connection with the Response Services. We acknowledge the dangers and risks to
which participation in Response Services may result in. Such risks include, without limitation,
death, injury, disease, burns, emotional trauma, illness, disability, extreme
noise, extreme lights and other damage to my person and/or property. _______ INITIALS OF PARENT/LEGAL GUARDIAN
I, as Participant, AGREE TO FOLLOW ALL INSTRUCTIONS,
PROCEDURES, MEASURES AND DIRECTIONS GIVEN BY RURAL/METRO AND UNDERSTAND MY
FAILURE TO DO SO MAY RESULT IN PROPERTY DAMAGE OR INJURY OR DEATH TO ME OR TO A
THIRD PARTY. I UNDERSTAND THAT MY
PARTICIPATION IN RESPONSE SERVICES MAY BE TERMINATED AT ANY TIME FOR ANY REASON
BY RURAL/METRO. ______ INITIALS OF PARENT/LEGAL
GUARDIAN
We, as Participant and Parent/Guardian, waive, release, discharge and indemnify Rural/Metro, its parent, subsidiaries and affiliates, and its and their respective officers, directors, stockholders, employees, agents, representatives, insurers, successors and assigns, of and from any claim, demand, right or cause of action, of any kind or nature whatsoever, whether based on tort, contract, warranty, or other theory of recovery, at law or in equity, vested or contingent, that I or my parents, legal guardian, spouse, family, children, estate, heirs, agents, insurers, successors or assigns may at any time have as a result of Participant’s participation in the Response Services. _____ INITIALS OF PARENT/LEGAL GUARDIAN
As Parent or Legal Guardian, I, as Participant, understand
that I am completely responsible for all insurance coverage which I may wish to
purchase to cover the activities contemplated herein.
WE, AS PARTICIPANT AND
PARENT/GUARDIAN, UNDERSTAND THAT THIS WAIVER, RELEASE AND INDEMNITY IS INTENDED
TO WAIVE, RELEASE, DISCHARGE AND INDEMNIFY IN ADVANCE RURAL/METRO, ITS PARENT,
SUBSIDIARIES AND AFFILIATES, AND ITS AND THEIR RESPECTIVE OFFICERS, DIRECTORS,
STOCKHOLDERS, EMPLOYEES, INSURERS, AGENTS, REPRESENTATIVES, SUCCESSORS AND
ASSIGNS, FOR, FROM AND AGAINST ANY AND ALL LIABILITY TO PARTICIPANT ARISING
FROM THE RESPONSE SERVICES. THIS INCLUDES,
WITHOUT LIMITATION, ANY LIABILITY (INCLUDING CONSEQUENTIAL, INDIRECT, SPECIAL
OR INCIDENTAL DAMAGES) ARISING FROM INJURY OR DAMAGE THAT I SUFFER OR CAUSE
DURING THE RESPONSE SERVICES, INCLUDING, WITHOUT LIMITATION, DEATH, INJURY,
EMOTIONAL TRAUMA, BURNS, ILLNESS, DISABILITY, EXTREME LIGHTS, EXTREME NOISE OR
OTHER DAMAGE TO MY PERSON AND/OR PROPERTY OR THIRD PARTY, AND ALL RISKS
CONNECTED THERETO, WHETHER FORESEEN OR UNFORESEEN, RESULTING FROM NEGLIGENCE OR
OTHERWISE. ______ INITIALS OF PARENT/LEGAL
GUARDIAN
We, as Participant and Parent/Guardian,
agree that this Waiver and Release is intended to be as broad and inclusive as
permitted by the laws of the State of ______________. If any provision of this Waiver and Release
shall be ineffective or invalid, such provision shall be ineffective or invalid
only to the extent of such prohibition or invalidity, without invalidating the
remainder of such provision or the remaining provisions of this Waiver and
Release, which shall remain in full force and effect. ______ INITIALS OF PARENT/LEGAL GUARDIAN
So long as Participant
participates in Response Services, in the event any representation or
obligation in this Agreement is no longer accurate, or true, we agree to inform
Rural/Metro immediately in writing of such occurrence. We realize that Rural/Metro is relying upon
our representations and agreements made in this Agreement and that any failure
to adhere to this Agreement could seriously injure someone, cause their death
or damage property. ______ INITIALS OF PARENT/LEGAL GUARDIAN
WE HAVE
READ THIS AGREEMENT AND THE WAIVER, RELEASE AND INDEMNITY BEFORE SIGNING IT,
AND FULLY UNDERSTAND, CONSENT AND AGREE TO ITS TERMS.
Minor
Participant:
By: _____________________________
Name: ___________________________
Date:
____________________________
CONSENTING Parent or Legal Guardian:
By: _____________________________
Name: ___________________________
Date:
____________________________