WAIVER, RELEASE & INDEMNIFICATION

AGREEMENT

______________________________, [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] living at _________________________________________________ [Insert Full Address] desire to participate in, observe and/or otherwise take part in Response Services. 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.

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:

I 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 acknowledge that I am not an employee or agent of Rural/Metro.

I 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, I 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 I expressly understand and agree that Rural/Metro makes no representation or warranty expressed or implied, written or oral regarding Response Services to me. _____ INITIALS

Given the very nature of Response Services, my participation in Response Services is inherently dangerous and risky. I 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

I voluntarily and freely, with full understanding that I may be exposing myself to extreme danger, assume all risks in connection with the Response Services that I choose to participate in. I acknowledge the dangers and risks to which I may subject myself by participating in Response Services. 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

I understand that if I have an infectious disease, or a medical condition which could be triggered by participating in Response Services or if I am not physically capable and mobile to enable me to move without assistance that I would endanger the public and/or myself so that I represent that I do not have any of the above conditions. ______ INITIALS

I 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

I understand that I am completely responsible for all insurance coverage which I may wish to purchase to cover my participation in the Response Services.

I 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 spouse, family, parents, children, estate, heirs, agents, insurers, successors or assigns may at any time have as a result of the Response Services for Rural/Metro. _____ INITIALS

I 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 ME ARISING FROM THE RESPONSE SERVICES RURAL/METRO IS INVOLVED IN. 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

I 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

So long as I participate in Response Services, in the event any representation or obligation of mine in this Agreement is no longer accurate, or true, I agree to inform Rural/Metro immediately in writing of such occurrence. I realize that Rural/Metro is relying upon my representations and agreements made in this Agreement and that my failure to adhere to this Agreement could seriously injure someone, cause their death or damage property. ______ INITIALS

I HAVE READ THIS AGREEMENT AND THE WAIVER, RELEASE AND INDEMNITY BEFORE SIGNING IT, AND FULLY UNDERSTAND AND AGREE TO ITS TERMS.

By: _____________________________

Name: ___________________________

Date: ____________________________