Release of Liability Waiver for Family Supports Services: Installation and/or Assembly of Sensory Equipment

Release of Liability Waiver for Family Supports Service: Installation and/or Assembly of Sensory Equipment
I First Name* Last Name* acknowledge that I am responsible for the installation and/or assembly of the equipment requested from Cuyahoga County Board of DD. I hereby agree to indemnify and hold harmless the Cuyahoga County Board of Developmental Disabilities and its employees or agents from and against any and all claims, suits, damages, or causes of action resulting in whole or part, directly or indirectly, from my installation and/or assembly of Item(s) being installed/assembled*
at my residence, and against any orders or decrees or judgments which may be entered therein, brought for damages or alleged damages, resulting from any injury to person and/or property or loss of life sustained by any person or persons whatever.
Signature of Individual named above:*

Clear
Date:*

YearMonthDay
Date
Email address:*
Name of Individual enrolled in the Family Supports Program:*

First NameLast Name
1275 Lakeside Avenue East, Cleveland, Ohio 44114-1129

216- 241-8230 www.CuyahogaBDD.org
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Release of Liability Waiver for Family Supports Service: Installation and/or Assembly of Sensory Equipment