LINK: SDIA Disaster Response Release and Liability Waiver Form APR2019

SHEEP DOG IMPACT ASSISTANCE

DISASTER RESPONSE RELEASE AND WAIVER OF LIABILITY FORM

 

This Release and Waiver of Liability Form (hereinafter the “Release”) is executed this                day of                                                                      , 20          , by                                                                                   (hereinafter the “Volunteer”) in favor of SHEEP DOG IMPACT ASSISTANCE, a nonprofit corporation organized and existing under the laws of the State of Arkansas, along with its directors, officers, employees, members, agents, affiliates, and volunteers (hereinafter collectively “SDIA”).

  1. Waiver and Release of Liability: Volunteer, for myself and for my heirs and assigns, hereby waives, releases and agrees to forever indemnify and hold harmless SDIA and its affiliates, agents, members, employees, volunteers, officers, directors, successors and assigns for any and all claims, causes of action, losses, or liabilities of any nature that may arise as a result of my participation in disaster response operations. This includes any and all claims for property damage, illness, bodily injury, personal injury, and/or death, even if such damage, illness, injury or death is caused by any of the parties’ negligence listed in the preceding sentence. If Volunteer is a minor, Parent/Guardian who executes below accepts full responsibility for the care and supervision of the minor during these activities. Further, I acknowledge and understand SDIA assumes no responsibility, and has no obligation, to provide financial or other assistance including, but not limited to medical, health or disability insurance in the event of property damage, illness, bodily injury, personal injury or death.
  2. Assumption of Risk: Volunteer acknowledges that by engaging in disaster response services and activities related to those services, said services and activities may be hazardous to me.  I understand those activities may include, but are not limited to, the following sorts of activities; travel to and from disaster areas, proximity to moving parts, cleaning up and exposure to debris from weather-related disasters, working in areas that may be without power and sanitation, operating and handling dangerous tools and equipment, etc.  I further acknowledge and understand that some situations may involve, and likely will involve, inherently dangerous activities.  I, for myself and for my heirs and assigns, expressly and specifically assume any and all risks of injury or harm, including death, and release and hold harmless SDIA from all liability for property damage, illness, bodily injury, personal injury, and/or death resulting from the activities engaged in while serving as Volunteer with SDIA.
  3. Insurance: Volunteer acknowledges that SDIA does not maintain, carry or provide property, health, medical or disability insurance coverage for Volunteer, and further acknowledges that SDIA expressly disclaims responsibility for providing property, health, medical or disability insurance coverage for volunteers assisting in emergency disaster response services and activities related to those services.
  4. Insurance Requirements: SDIA EXPECTS AND ENCOURAGES VOLUNTEER TO CARRY BOTH LIABILITY AND MEDICAL/HEALTH INSURANCE PRIOR TO VOLUNTEERING FOR EMERGENCY DISASTER RESPONSE SERVICES.
  5. Medical Treatment: Should Volunteer require any medical treatment, medical services or first-aid treatment while assisting in emergency disaster response services with SDIA, Volunteer, for itself and its heirs and assigns, agrees to forever release, discharge and indemnify SDIA from any claim whatsoever which arises as a result of said medical or first-aid treatment in connection with assisting in emergency disaster response services with SDIA.  Volunteer further agrees to provide any and all medical history if emergency medical treatment is required.
  6. Photographic Release: Volunteer grants and conveys unto SDIA all right, title and interest in any and all photographic images and video or audio recordings made by SDIA while serving as Volunteer. SDIA will have the right to freely reproduce, publish and/or circulate any photographic images and video or audio recordings in their sole discretion.  Volunteer acknowledges that Volunteer will not be entitled to any compensation, including, but not limited to any royalties, proceeds or other benefits derived from such photographs or recordings.
  7. Current Health: Volunteer acknowledges that they have no known physical or mental conditions that would impair their capability to fully participate as intended or expected by SDIA.
  8. Other: I, as Volunteer, acknowledge it is my desire to assist SDIA in providing emergency disaster response services and participate in activities related to those services.  I further acknowledge and understand I am performing said services as a volunteer and will be owed no compensation and that, in performing said services, I am not acting as an employee or agent of SDIA.

 

This Release is being executed as a result of my free and voluntary desire, and without any duress.  To further acknowledge my understanding of this Release, I have executed this with a witness.

 

Volunteer Information:

Name:                                                                                                                                                    Phone:                                                                          

Email:                                                                                                                                                    DOB:                                                                             

Mailing Address:                                                                                                                                                                                                                     

Signature:                                                                                                                                            Date:                                                                             

*To be signed by Parent/Guardian if Volunteer is under 18 years old

 

Emergency Contact:

Name:                                                                                                                                                    Relation:                                                                     

Phone:                                                                                                                                

 

Witness Information: 

Name:                                                                                                                                                    Signature:                                                                   

 

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