Fill and Sign the Waiver and Release from Liability for Adult for Healthcare Form

WAIVER AND RELEASE FROM LIABILITY FOR HOME HEALTH CARE I, ________________________ , HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge ________________________ and its agents, participants, employees, officers, directors, affiliates, successors, members, trustees, managers 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 I ever had or may have, arising from or in any way related to the in home nursing care being provided to me provided that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct. I understand that the health related assistance being provided to me may be inherently dangerous and can cause serious or grievous injuries, including bodily injury, damage to personal property and/or death. On behalf of myself, my heirs, assigns, and next of kin, I waive all claims for damages, injuries and death sustained to me or my property, that I may have against the aforementioned released party to such activity. By this Waiver, I assume any risk, and take full responsibility and waive any claims of personal injury, death or damage to personal property associated with ________________________ including but not limited to receiving home health care assistance, using any of the equipment in any manner, form or fashion, or engaging in any medical care or rehabilitative therapy from the attending nurse or assistants. This WAIVER AND RELEASE contains the entire agreement between the parties, and supercedes any prior written or oral agreements between them concerning the subject matter of this WAIVER AND RELEASE. The provisions of this WAIVER AND RELEASE may be waived, altered, amended or repealed, in whole or in part, only upon the prior written consent of all parties.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 WAIVER AND RELEASE will continue in full force and effect even after the termination of the activities conducted by, on the premises of, or for the benefit of ________________________ , whether by agreement, by operation of law, or otherwise. I have read, understand and fully agree to the terms of this WAIVER AND RELEASE. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this waiver. ____________ Date ________________________ Printed Name ________________________ Signature Copyright 2004 USLegalforms.com