Lakewood Animal Hospital - Surgery Consent Form

If you are under 19, the consent of your parent or guardian is required in order for you to
volunteer. Please have a legal guardian complete the following with you:

Applicant Name (Referred to as the minor in this document)*

First Name of MinorLast Name of Minor

Applicant Phone Number

Please enter a valid phone number.

Legal Guardian Name (Referred to as the legal guardian in this document)*

First NameLast Name

Legal Guardian Phone Number*

Please enter a valid phone number.

Legal Guardian Email*

example@example.com

Minor Birth Date ( Must be 16 years of age or OLDER to volunteer)*

MUST BE 16 YEARS OF AGE OR OLDER TO VOLUNTEER

In exchange for participation in the activity of observing and shadowing hospital staff organized by Lakewood Animal Hospital P.C. Ltd. (Lakewood Animal Hospital), of 1151 Lakewood Court North, Regina, Saskatchewan, S4X 3S3 and/or use of the property, facilities and services of Lakewood Animal Hospital, I agree to the following:

1. MINOR: I, the minor, agree that I will observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Lakewood Animal Hospital, or the employees, representatives or agents of Lakewood Animal Hospital.*

YES, I agreeNO, I do not agree

LEGAL GUARDIAN : I, the legal guardian, understand and agree that the minor will observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Lakewood Animal Hospital, or the employees, representatives or agents of Lakewood Animal Hospital.*

YES, I agreeNo, I do not agree

2. I, the legal guardian, recognize that there are certain inherent risks associated with the above activity and I assume full responsibility for personal injury on behalf of the above minor, and further release and discharge Lakewood Animal Hospital for injury, loss or damage arising out of their use of or presence upon the facilities of Lakewood Animal Hospital, whether caused by the fault of the minor, Lakewood Animal Hospital or other third parties.*

YES, I agreeNO, I do not agree

3. I, the legal guardian, agree to indemnify and defend Lakewood Animal Hospital against all claims, causes of action, damages, judgements, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from the above minor's use or presence on the facilities of Lakewood Animal Hospital.*

YES, I agreeNO, I do not agree

4. I, the legal guardian, consent to the participation in observing and shadowing hospital staff, and agree on behalf of the above minor to all the terms and conditions of this Agreement.*

YES, I consent and agreeNO, I do not consent and do not agree

5. I, the legal guardian, agree and acknowledge that I am under no pressure or duress to sign this Agreement on behalf of the above minor and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this Agreement if I so desire.*

YES, I agreeNO, I do not agree

6. MINOR: I, the minor, understand that even though I am not providing direct patient care at Lakewood Animal Hospital, I will see and hear confidential information about patients and clients of Lakewood Animal Hospital. ('Confidential information' includes any information learned while at the hospital, either verbal or written, paper or electronic.) I understand that ANY information about patients and clients is private - that means it must NOT be shared with others without written consent of the individual client. I understand that even the fact that a patient is in the hospital is a confidential piece of information - I am not allowed to share this with anyone else, including my family. Breach of confidentiality is grounds for immediate dissmssial and/or legal action.*

YES, I understand and I will not share confidential information about clients and patientsNO, I do not understand

I, THE MINOR, HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS

Minor Print Name*

First NameLast Name

Minor Digital Signature

I have legal authority and custody of the minor named above*

YES, I have legal authority and custody of the minor named aboveNO, I do not have legal authority and custody of the minor named above

I, the undersigned, understand that by signing this Release of Liability, I represent that I have legal authority and custody of the minor named above. I have read this document and I understand that by signing this release, I voluntarily surrender certain legal rights for myself and the above named minor. I grant my permission to my son/daughter/legal dependent to serve as a volunteer at Lakewood Animal Hospital.*

YES, I have legal authority and custody of the minor named above and agree.NO, I do not have legal authority and custody of the minor named above and I do not agree.

In the event of a medical emergency while he/she/they is volunteering for the Lakewood Animal Hospital, I authorize whatever emergency medical treatment is deemed essential by responsible medical attendants.*

Yes, I agreeNo, I do not agree

Emergency Contact Name and Number (if different from above)*

Legal Guardian Name*

First NameLast Name

Guardian Digital Signature*

Volunteer Application Minor

Volunteer Release of Liability Form