Fill and Sign the Release Liability Form

Release and Waiver of Liability for Participation by Resident of Independent Living Facility in Travel Offsite for Weekly Shopping Trips Agreement made on the ________ day of__________________________________, 20_____, between __________________________________________ (Name of Resident of Independent Living Facility) of ___________________________________________________ ______________________________________________________________________________ _______________ (street address, city, county, state, zip code), referred to herein as Resident , and _______________________________________________________ (Name of Independent Living Facility) located at ________________________________________________________ ______________________________________________________________________________ _______________ (street address, city, county, state, zip code), referred to herein as Facility ; Whereas, Facility is an organization which operates as an independent living facility that houses and cares for its residents and desires to offer weekly transportation by an employee of Facility who holds a valid driver’s license in the state of _________________________ for its residents to and from local shopping establishments; and Whereas, ____________________________________the undersigned Resident desires t o participate in such shopping excursions. Now, therefore, for and in consideration of participating in the offsite travel for weekly shopping trips conducted by Facility , Resident hereby waives and releases, indemnifies, holds harmless and forever discharges Facility and its agents, employees, officers, directors, affiliates, successors and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that Resident ever had or may have, arising from or in any way related to Resident’s participation in such shopping activities provided that this Release and Waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct. Resident hereby authorizes and grants permission for an employee of Facility with a valid driver’s license in the state of ___________________________________ to transport Resident to and from the shopping location(s). Resident agrees and hereby does release and hold harmless the Facility and/or any and all adult supervisors for the shopping activity and authorized persons transporting residents to and from local stores/shops, from and for any and all liability which may arise for damages, loss or injuries, either to person or property, which Resident may sustain while engaging in the shopping activities including, but not limited to, any damages, loss or injuries that may be sustained through transportation to and from the shopping activities, except as to such injuries or damages arising from the intentional conduct or the sole negligence of Facility and/or its supervisors, leaders or employees. Resident further agree(s) to assume responsibility for any liability which may arise for damages, loss or injuries, as described herein which may be caused or contributed to by Resident to the person or property of others. By this Release and Waiver, Resident assumes any risk, and takes full responsibility and waives any claims of personal injury, death or damage to personal property associated with the transportation/shopping activities conducted off the Facility’s premises. Resident has the necessary and requisite skills to participate in all facets of the shopping activities, the nature of the activities has been fully disclosed and any flyer, advertisement, or brochure relating to the shopping activities is expressly made a part of this Release and Waiver. This Release and Waiver contains the entire agreement between the parties, and supersedes any prior written or oral agreements between them concerning the subject matter of this Release and Waiver. The provisions of this Release and Waiver may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of all parties. The provision of this Release and Waiver will continue in full force and effect from the date it is signed until Resident no longer participates in the Facility’s transportation services/shopping activities whether by agreement, by operation of law, or otherwise. Resident has read, understands and fully agrees to the terms of this Release and Waiver. Resident understands and confirms that by signing this Release and Waiver Resident has given up considerable future legal rights. Resident has signed this Release and Wavier freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to Resident . Resident’s signature is proof of Resident’s intention to execute a complete and unconditional Release and Waiver of all liability to the full extent of the law. WITNESS my signature this the _____ day of____________________________, 20______. ________________________________________ Signature of Resident ________________________________________ Type or Print Name ________________________________________ Signature of Representative of Facility ________________________________________ Type or Print Name