VETERANS IN PAIN WAIVER AND RELEASE OF LIABILITY
In consideration of the possible risk of injury or death due to accepting the physician referral for potential medical treatment via the Veterans In Pain program, facilitating regenerative and alternative medical solutions for Veterans in chronic pain, (the "Referral""), and as consideration for the right to accept the Referral, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my acceptance of the Referral, and do hereby release and forever discharge Veterans In Pain, a 501c3 IRS certified nonprofit, located at 28050 Liana Ln, Valencia, California 91354, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, decrease in quality of life, and/or results which do not increaswe my quality of life, that I may suffer as a direct result of my participation in the Veterans In Pain program and acceptance of aforementioned Referral, including traveling to and from any occasion surgical or otherwise related to this Referral or any Veterans In Pain activity.
I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED REFERRAL AND SURROUNDING ACTIVITIES AND I AM ACCEPTING THE PHYSICIAN REFERRAL AND SUBSEQUENT MEDICAL TREATMENT AND ALL ACTIVITY RELATED TO SAID ACCEPTANCE, ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH TRAVELING TO AND FROM AS WELL AS PARTICIPATING IN THIS REFERRAL, ACCEPTANCE OF TREATMENT, SURGERY, TREATMENTS, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' INCLUDING PHYSICIAN NEGLIGENCE, CONDITIONS RELATED TO TRAVEL, OR THE CONDITION OF THE REFERRAL LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN OR UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY AND ACCEPTANCE OF MEDICAL TREATMENT, INCLUDING TRAVEL TO, FROM AND DURING THIS ACTIVITY OF HAVING ACCEPTED MEDICAL CARE THROUGH VETERANS IN PAIN BY HAVING APPLIED TO THIS PROGRAM. VETERANS IN PAIN HAS ACTED IN GOOD FAITH, AND I UNDERSTAND THEIR GOAL IS TO SIMPLY CONNECT VETERANS SUFFERING FROM CHRONIC PAIN WITH PHYSICIANS WHO OFFER THEIR SERVICES FREE OF CHARGE TO VETERANS REFERRED BY THIS PROGERAM. IT IS THE VETERAN'S RESPONSIBILITY TO VET THIS PHYSICIAN AS HE OR HER WOULD DO WITHOUT APPLICATION TO ANY OUTSIDE FACILITATOR.
I agree to indemnify and hold harmlessVeterans In Pain, a 501c3 IRS certified nonprofit against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Veterans In Pain, a 501c3 IRS certified nonprofit incurs any of these types of expenses, I agree to reimburse Veterans In Pain, a 501c3 IRS certified nonprofit.
I acknowledge that Veterans In Pain, a 501c3 IRS certified nonprofit and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Veterans In Pain, a 501c3 IRS certified nonprofit.
I ACKNOWLEDGE THAT THIS REFERRAL AND SUBSEQUENT TREATMENT(S) MAY REUSULT IN COMPLICATIONS WHICH ARE OUT OF THE CONTROL OF VEWTERANS IN PAIN AND ITS ASSOCIATES WHICH MAY IMPARE A PERSON'S PHYSICAL AND MENTAL HEALTH AND MAY CARRY WITH IT THE POTENTIAL FOR DEATH, SERIOUS INJURY, AND PROPERTY LOSS. The risks may include, but are not limited to, those caused by the physician, facilities, temperature, weather, condition of participants, vehicular traffic to and from locations, and actions of others, including but not limited to, participants, and volunteers.
I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Veterans In Pain, a 501c3 IRS certified nonprofit AND ALL OF ITS AFFILIATES, MEMBERS, AGENTS, AMBASSADORS, ATTORNEYS, STAFF, VOLUNTEERS,
HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Veterans In Pain, a 501c3 IRS certified nonprofit FOR PERSONAL INJURY OR DAMAGE TO SELF AND/OR COMPANION AT ANY POINT THROUGHTOUT THEIR ASSOCIATION WITH VETERANS IN PAIN AND ITS ACTIVITIES.
To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Veterans In Pain, a 501c3 IRS certified nonprofit, its agents, and employees.
In the event that I should require additional medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.
In the event that any damage occurs to self as a result of my or my family's willful actions, neglect or recklessness, during post operative, post treatment recovery, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness.
This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the Participant, __________________________, and Veterans In Pain, a 501c3 IRS certified nonprofit agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
I, the undersigned participant, affirm that I am of the age of 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of personal, professional, and medical liability and a contract and that I am signing it of my own free will.