LSP Registration Form

First Name

Last Name

E-mail*

example@example.com

Department*

Baby's Birth Date/Due Date*

Date

What is your association with UC Davis?*

How did you hear about this program?*

Where is your primary working location?*

Where is your anticipated primary pumping location?*

I have read and agree with the UC Davis elective/voluntary activity waiver below (You must select "Yes" to participate)*

YesNo

ELECTIVE/VOLUNTARY ACTIVITY WAIVER

UNIVERSITY OF CALIFORNIA DAVIS

Breastfeeding Support Program

Waiver of Liability, Assumption of Risk and Indemnity Agreement

Waiver: In consideration of being permitted to participate in any way in the Breastfeeding Support Program (BFSP), I for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue The Regents of the University of California, its officers, employees, and agents from liability from any and all claims including the negligence of The Regents of the University of California, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to:

Use of lactation sites and equipment used in BFSP including but not limited to, the Ameda Egnell/Medela electric breast pumps and the breast pump kits.
Instruction received during consultation, support group, and.or other educational activities of BFSP.

Assumption of Risks: Participation in BFSP carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from:

Being unable to pump if pump should break, if there is an electrical power failure, or if lactation site should be occupied by another participant, or other reasons.
Discomfort of nipples and/or areola.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in pump kit and room use. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDENMIFY AND HOLD the Regents of the University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in BFSP and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including the right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

Lactation Support Program Registration Form