Fill and Sign the Below is a Copy of Our Waiver that Will Piney Hills and Form

Page 1 of 1 Video Surveillance Agreement and Release This Agreement is made , between (date) , (Name of Releasor) hereinafter called Releasor, and , (Name of Guardian) hereinafter called the Guardian, of , referred to (Name of Ward)herein as the Ward, who resides at , (street address, city, state, zip code) herein referred to as the PremisesWhereas, I understand that Ward is mentally challenged and that he and Guardian live at separate locations; andWhereas, I understand that it is important that Guardian observe the Ward’s interactions with people that come to the Premises for any reason such as to tutor him, act as his caregiver, give him therapy, or just visit; andWhereas, I acknowledge that I have received a copy of this Video Surveillance Agreement and Release;Now, therefore for good and valuable consideration, I hereby agree to the following:1.I have been given the opportunity to read and ask any questions that I might have about this Agreement and Release.2. I further understand that in order to promote the safety, health, education and therapy of Ward, as well as the security of the Premises of Ward, Guardian may conduct video surveillance (with audio also being recorded) of any portion of the Premises at any time, the only exception being private areas of restrooms, showers, and dressing rooms, and that such video cameras and audio recording devises will be positioned in appropriate places within and around the Premises and used for the reasons as set forth above. 3.I hereby give my consent to such video and audio surveillance being conducted while I am on the Premises and in and around the Premises of Ward and consent to a video and audio recording being made of me while on the Premises of Ward.4. I hereby release Guardian and Ward from any and all liability directly or indirectly resulting from such the making or review of such video and audio recordings of me. WITNESS my signature this the ____ day of ______________, 20______.(Signature (Signature of Witness) Print or Type Name Print or Type Name