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  • Chariot Service Center: Client Intake Form

    This form is lengthy and extensive and may take up to 1 hour to complete. If at any point you need to save your progress and finish later, you can click on the "save" button at the bottom of the page. We recommend taking short breaks periodically to make the process more manageable. If you have any questions, please reach out for clarification.

  • Introduction:

    All information shared through this form is considered strictly confidential and will only be available to the client, the facilitator, and the licensed representatives of the service center. A client must review and complete this client information form prior to participating in an administration session. A facilitator must provide this form in other languages or accessible formats upon a client’s request. If a facilitator is unable to provide a translated or accessible client information form upon a client’s request, they may not conduct an administration session with the client.

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  • Client Information Form

    Introduction: A client must review and complete this client information form with a facilitator prior to participating in an administration session. A facilitator must provide this form in other languages or accessible formats upon a client's request. If a facilitator is unable to provide a translated or accessible client information form upon a client's request, they may not conduct an administration session with the client.
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  • Please provide a narrative answer to the following questions.

  • For clarification, an "Administration Session" is the term used to describe the time when you ingest the psilocybin and experience its effects in the approved facilities of the service center under the supervision of your facilitator. Depending on the dosage, the Administration Session usually lasts between 4-6 hours.

    • Facilitator Review and Evaluation 

    • Facilitator Review and Evaluation

      • This section of the Client Information Form is used by the facilitator. A facilitator must evaluate the answers to questions listed in the Client Information Form as outlined in OAR 333-333-5050 (3) to determine whether the client should participate in an administration session. 

      • If a client answers yes to question (3)(a), the client may not participate in an administration session.

      • If a client answers yes to question (3)(b), a facilitator shall encourage the client to consult a medical, clinical, or other healthcare provider regarding the risk of consuming psilocybin.

      • If a client answers yes to question (3)(c), the client should be encouraged to consume an alternative psilocybin product rather than whole fungi or homogenized fungi during the administration session.

      • If a client answers yes to question (3)(d), a facilitator should encourage the client to schedule their administration session at a time that allows them to participate without taking medication. A facilitator should also encourage the client to consult with a pharmacist or medical, clinical, or other healthcare provider regarding contraindications. If the client will take medication during an administration session, the client and facilitator must work together to identify whether the client will be able to administer the medication themselves. If the client is unable to administer the medication themselves, the client must identify a client support person who will be available to administer the medication when required.

      • If a client answers yes to question (3)(e), the client and facilitator must work together to identify an appropriate interpreter who will be present in person or virtually during the client’s administration session.

      • If a client answers yes to question (3)(f), the client and facilitator must work together to create a written assistance or medical device plan.

        • If the client requires a medical device, the medical device plan must describe the required medical device and indicate whether the client will be able to use the medical device without assistance. If the client is unable to use the medical device without assistance, the written medical device plan must identify a client support person who will be available to assist the client with their medical device when required.

        • If the client requires assistance with catheter, ostomy, or toileting assistance, ambulation or transfer mobility support, the assistance plan must identify the type of assistance required and a client support person who will be available to assist the client.

      • If a client answers yes to question (3)(g), the client and facilitator must work together to identify an appropriate client support person who will be present during the client’s administration session to assist with the client’s alternative communication device support or assistive listening device support during the administration session.

      • If a client answers yes to question (3)(h), the client may not participate in an administration session.

      • If a client answers yes to question (3)(i), a facilitator shall encourage the client to consult with a medical or clinical provider regarding the risk of consuming psilocybin.

      • If a client answers yes to question (3)(j), the client may not participate in an administration session.

      • If a client answers yes to question (3)(k), the facilitator must inform the client that the risks of consuming psilocybin while pregnant or feeding with breast milk are unknown.

      • If a client answers yes to question (3)(l), the client and facilitator must work together to create a written plan that describes how the client will safely exit the service center in the event that an emergency occurs during their administration session.

      • If a client answers yes to question (3)(m), the client and facilitator must work together to identify an appropriate client support person who will be present to assist the client with consuming psilocybin products during their administration session.

      • If a client answers yes to question (3)(n), the client and facilitator must work with the client to create a written plan that describes how the facilitator will take reasonable steps to accommodate the conditions, sensitivities or health concerns identified by the client. For example, if a client has a compromised immune system, the written plan will describe efforts to prevent the transmission of viruses and bacteria.
         

  • By signing this form, I acknowledge that I have reviewed and completed this form in coordination with a psilocybin services facilitator prior to participating in an administration session.

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  • By signing this form, I acknowledge that I have reviewed and completed this form with the client prior to the client participating in an administration session.

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  • Supplemental Questions

    These questions are a way for me to better understand who you are and how I can best facilitate for you.

  • Informed Consent

    Introduction: In the State of Oregon, psilocybin services include a preparation session, administration session, and integration session. You should receive this informed consent form prior to or during your preparation session. During the preparation session, your facilitator will review and discuss this form with you. Please make sure you read and understand every section because you must sign the form before the administration session begins. If you do not understand any part of this document, please ask your facilitator for clarification before signing.

  • I have been informed of and understand the following:

    (Please initial each item below)

  • 1.*I have reviewed the Psilocybin Services Client Bill of Rights, my facilitator has explained it to me, and I understand my rights as a client.

  • 2. *I understand that psilocybin services do not require medical diagnosis or referral and that psilocybin services are not a medical or clinical treatment.

  • 3.*I understand that psilocybin has not been approved by the Food and Drug Administration and the federal government currently classifies psilocybin as a Schedule I controlled substance under the Controlled Substances Act.
    a. Federal law prohibits the manufacture, distribution, and possession of psilocybin even in cities and states that have adopted laws to allow its possession or use.
    b. Despite its federal Schedule I status, research suggests that psilocybin is very unlikely to be addictive. Additionally, research and other information suggests that psilocybin may improve symptoms of depression, anxiety, end of life distress, various forms of trauma, and problematic substance use.

  • 4. *I understand that the risks, benefits, and drug interactions of psilocybin are not fully understood, and individual results may vary.

  • 5. *I understand that some people have found psilocybin administration sessions to be challenging or uncomfortable. Common potential side effects include nausea, mild headache, fatigue, anxiety, confusion, increased blood pressure, elevated heart rate, paranoia, perceptual changes, altered thought patterns, reduced inhibitions, recovery of repressed memories and past traumas, and altered perception of time and one's surroundings. If they occur, these side effects are usually mild and temporary. Because the potential risks and benefits of psilocybin administration are not fully understood, there may be unanticipated side effects.

  • 6.*I understand that if I am taking prescription medications or have a medical condition or mental health condition, I should consider consulting with a medical or clinical provider before participating in an administration session.

  • 7.*I understand that psilocybin is derived from fungi. If I have a known mushroom allergy, I should consult with a medical or clinical provider before participating in an administration session.

  • 8.*I understand that the risks of consuming psilocybin while pregnant or feeding with breast milk are unknown.

  • 9.*I have discussed acceptable types of supportive touch and the requirement to provide prior written consent prior to the start of my administration session.

  • 10.*I understand that facilitators may be mandatory reporters of abuse. If my facilitator is a mandatory reporter, they have shared this information with me and explained their legal obligations to report abuse.

  • 11.*I understand that facilitators have a duty to report misconduct that harms or endangers a client to the Oregon Health Authority. If the misconduct presents an immediate risk to health and safety, facilitators have a duty to contact emergency services.

  • 12.*I agree to follow my agreed upon transportation plan. I understand that a facilitator may contact emergency services if failure to follow my transportation plan presents a risk to my safety or the safety of others.

  • 13.*I understand that consuming psilocybin is completely voluntary and I may decide not to consume psilocybin at any time.

  • 14.*I understand that I have the right to update my client information form prior to beginning an administration session and I have the right to receive a copy of my client information form upon request.

  • 15.*I understand that if de-identified data collected by facilitators and service centers is shared with people and institutions outside of the facilitator or psilocybin service center, I must be provided with a disclosure form that describes who will receive the data and how it will be used, and that I have the opportunity to opt-out of having my de-identified data provided to third parties . the Psilocybin Services Client Bill of Rights, my facilitator has explained it to me, and I understand my rights as a client.

  • 16.*I understand data that may be used to identify me as a client will only be shared to the extent permitted or required by law. Specifically, 475A.450 allows disclosure in the following circumstances:
    (1) When the client or a person authorized to act on behalf of the client gives consent to the disclosure;
    (2) When the client initiates legal action or makes a complaint against the psilocybin service center operator, the psilocybin service facilitator, or the employee;
    (3) When the communication reveals the intent to commit a crime harmful to the client or others;
    (4) When the communication reveals that a minor may have been a victim of a crime or physical, sexual or emotional abuse or neglect; or
    (5) When responding to an inquiry by the Oregon Health Authority made during the course of an investigation into the conduct of the psilocybin service center operator, the psilocybin service facilitator, or the employee under ORS 475A.210 to 475A.722.

  • 17.*I understand that my facilitator may take short restroom breaks during my administration.

  • 18.*I understand that leaving a psilocybin service center during an administration session once it has begun is strongly discouraged. Doing so could lead to safety and legal risks.

  • 19.*I understand and have been informed of the potential benefits, risks, and complications of psilocybin services with my facilitator to the extent that they are known.

  • 20.*My facilitator has shared locations of client restrooms and protocols for use of restrooms during an administration session.

  • 21.*My facilitator has shared information regarding verification of license status and process for making complaints to the Oregon Health Authority.

  • 22.*I have had the opportunity to ask questions regarding anything I may not understand or that I believe should be made clear.

  • 23.*If participating in a group administration session, I understand that I will be experiencing the effects of psilocybin in the presence of other clients who are also experiencing the effects of psilocybin and may be reacting to the experience in a different manner.

  • 24.*I acknowledge that the risks and benefits of consuming doses greater than 35 mg of psilocybin analyte are unknown.

  • 25.*If consuming whole fungi during an administration session, I understand that psilocybin content can vary between individual fruiting bodies.

  • 26.*I understand that the risks and benefits of repeated psilocybin use are unknown.

  • 27.*I understand that a facilitator has a duty to call emergency services if required and a client assumes responsibility for costs of emergency services.

  • 28.*I understand that I will be required to identify an emergency contact and a facilitator or service center may contact this person in the event of a medical or other emergency.

  • 29.*I understand that I may be charged a cancellation fee if I cancel a scheduled preparation, administration or integration session.

  • 30.*I understand that I have the right to choose my facilitator and if a facilitator has supervisory, evaluative, or other authority over me, I will be provided an opportunity to receive psilocybin services from another facilitator.

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  • Client Bill of Rights

    Instructions Oregon Administrative Rules (OAR) Division 333, Chapter 333 detail the language and rule requirements of the Client Bill of Rights. The Client Bill of Rights and these instructions may be found on the Oregon Psilocybin Services (OPS) Forms webpage.

  • ► A service center must post the following Client Bill of Rights in a prominent location within the licensed premises and must provide every client with a copy during their preparation session.

    ► A facilitator or service center must provide the Client Bill of Rights in other languages or accessible formats upon a client's request.

    ► A facilitator or service center must provide the Client Bill of Rights to a client prior to a preparation session upon the client's request.

    ► A facilitator must review the Client Bill of Rights with a client during a preparation session.

    ► A facilitator must provide a copy of the Client Bill of Rights and allow an interpreter or client support person an opportunity to ask questions.

    ► The text of the Client Bill of Rights may not be altered and must be printed in an easily legible font.

  • Client Bill of Rights

  • Clients receiving psilocybin services in Oregon have the following rights:

  • 1. To be treated with dignity and respect while receiving psilocybin services.

    2. To receive competent and equitable care consistent with values, policies, and practices that ensure all people, especially those who have been historically marginalized based on race, ethnicity, religion, language, disability, age, gender, gender identity, sexual orientation, social class, intersections among these communities or identities, or other socially determined circumstances are considered in the development of social pathways to health equity.

    3. To be free from physical, sexual, psychological, and financial abuse before, during, and after receiving psilocybin services.

    4. To make decisions without coercion or undue influence.

    5. To be informed of the known benefits and risks associated with psilocybin services.

    6. To refuse psilocybin services prior to beginning an administration session.

    7. To privacy and confidentiality regarding participation in psilocybin services.

    8. To refuse to release any information to third parties, except as required by law. Information may be required to be released by law when a client initiates a complaint, when communications reveal an intent to cause harm to others or disclose that a minor may have been a victim of abuse, or when responding to an investigation by Oregon Health Authority.

    9. To full disclosure of any facilitator conflicts of interest.

    10. To a full and accurate explanation of the costs associated with receiving psilocybin services before receiving those services.

    11. To store personal belongings securely while receiving psilocybin services.

    12. To access their client records after providing reasonable notice to a facilitator or service center and to correct information that is inaccurate.

    13. To request a private space in which to receive psilocybin services.

    14. To be monitored and supported by a licensed facilitator for the duration of psilocybin services until it is safe for the client to leave the service center.

    15. To receive psilocybin services from a licensed facilitator for the duration of those services, except in cases of emergency.

    16. To access service centers, therapy rooms, and psilocybin services that are welcoming and accessible to people with disabilities.

    17. To have access to a clean, single occupancy restroom for the duration of psilocybin services.

    18. To discuss this Bill of Rights with licensed facilitators and service center operators without facing discrimination or retaliation.

    19. To report violations of this Bill of Rights to the Oregon Health Authority, or other appropriate governing body, without facing discrimination or retaliation.

    20. To withdraw or alter my consent to receive psilocybin services at any time prior to beginning an administration session.

    21. To withdraw or alter my consent to release information.

    22. To receive services in a manner that considers my individual conditions, sensitivities, and health concerns.

    23. To be fully informed of a service center's policies on possession of firearms and other weapons on the licensed premises.

    24. To make complaints to the Oregon Health Authority regarding psilocybin products and services.

  • I have reviewed and understand the Client Bill of Rights

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  • Client Transportation Plan

  • Every client who receives psilocybin services must complete and sign a
    Transportation Plan that describes how the client will access safe
    transportation after completing an administration session.

    Safe transportation does not include a client operating a motor vehicle,
    bicycle, or other form of self-operated transportation directly after their
    administration session.


    If a client is unable to follow their transportation plan, a facilitator must
    make reasonable efforts to arrange for alternative transportation. If
    facilitators are unable to resolve safety issues caused by a client's failure to follow their transportation plan, facilitators must contact appropriate
    emergency services.

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  • By signing this form, I acknowledge that I have reviewed and completed this client transportation plan with a psilocybin services facilitator prior to participating in an administration session.

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    • Facilitator Review & Signature 

    • By signing this form, I acknowledge that I have reviewed and completed this client transportation plan with the client prior to the client participating in an administration session.

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  • Client Safety & Support Plan

  • Every client who will participate in an administration session is required to complete a Safety and Support Plan during a preparation session with a licensed facilitator. The Safety and Support Plan identifies risks and challenges specific to the client's circumstances and resources available to address those risks and challenges, including the client's existing support network and appropriate external resources.

    This form may be used as a template for Safety and Support Plans which must be completed in coordination with client and facilitator.

    Safety and Support Plans may not be changed during an administration session.

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  • Emergency Contact

    Please identify a person to be contacted in the event of a medical or other emergency.

  • By signing this form, I acknowledge that I have reviewed and completed this Client Safety and Support Plan with a psilocybin services facilitator prior to participating in an administration session.

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    • Facilitator Review & Signature 

    • By signing this form, I acknowledge that I have reviewed and completed this Client Safety and Support Plan with the client prior to the client participating in an administration session.

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  • NOTICE AND OPT-OUT OF DISCLOSURE OF DE-IDENTIFIED DATA

    Psilocybin service center operators, psilocybin facilitators, or employees of psilocybin service centers or psilocybin facilitators, are not allowed to disclose any information that may be used to identify you, a client of psilocybin services in Oregon, without your consent. (ORS 475A.450)

    Psilocybin service center operators, psilocybin facilitators, or employees of psilocybin service centers or psilocybin facilitators are allowed to disclose de­identified information to third parties, which is information that cannot be used to identify you, unless you opt-out. This notice is intended to provide you with information about what de-identified information may be disclosed to third-parties and for what purposes and to give you the opportunity to opt out of having your de-identified data disclosed. (OAR 333-333-4810) This notice must be used to provide clients information on disclosure of de-identified data. Licensees may not use their own notice forms.

    Please review it carefully.

    "De-identified data" means aggregate data from which the Authority or licensee has deleted, redacted, or blocked identifiers to ensure that the remaining information cannot reasonably be used to identify an individual client. (OAR 333- 333-1010 (23))

  • Acknowledgement

  • I, [name of client]   *   * received a copy of this form on [date]   Pick a Date*   

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  • Opt-Out Statement optional

  • I, [name of client]       OPT-OUT of having my de-identified data disclosed to third parties by the service center or facilitator named above.      

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  • Consent for Video and Audio Recording of Administration Sessions - Individual Administration Session

  • Instructions: Recording of individual administration sessions is optional and requires prior written consent from every client and facilitator who will be present during a recorded administration session. Please use this form to document both client and facilitator consent to being recorded during the administration session. Administration sessions are not allowed to be recorded without prior written consent from every client and facilitator present during the administration session. A separate form must be used for each individual administration session.

    Administration sessions must be recorded using service center equipment. Service centers are responsible for retaining and maintaining confidentiality of recordings pursuant to the requirements of OAR 333-333-4640. Clients may view the recordings at the service center location upon request.

    Clients and facilitators must provide separate written consent using an Authorization to Disclose Personal Identifiable Information to allow recordings to be published, shared, or otherwise distributed.

    Clients and facilitators may withdraw their consent to record an administration session at any time prior to beginning an administrative session.

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    • Facilitator Review & Signature 
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  • Client Consent for Use of Supportive Touch During Administration Session

  • Instructions:

    Clients have the option of allowing a facilitator to use supportive touch during their administration session. Facilitators may provide supportive touch when requested by the client and with the client's prior written consent. Clients participating in group sessions may also authorize other clients to use supportive touch. Supportive touch is limited to hugs or placing hands on a client's hands, feet, or shoulders. All other forms of touch are prohibited during an administrative session. Clients may withdraw their consent to use supportive touch at any time during the administration session.

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  • Please select whether you consent or do not consent below.

  • OR

  • By signing this form, I acknowledge that I have reviewed and completed this form in coordination with a psilocybin services facilitator prior to participating in an administration session.

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    • Facilitator Review & Signature 

    • By signing this form, I acknowledge that I have reviewed and completed this form with the client prior to the client participating in an administration session.

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  • Client Consent to Receive Secondary Dose of Psilocybin Product

  • Instructions: A service center may permit a client to consume a secondary dose of psilocybin product during an administration session based on the agreements made between the licensed facilitator and the client regarding product type and dosage during the preparation session. The total amount of psilocybin analyte consumed must not exceed 50 mg.

    Clients must purchase the secondary dose prior to beginning their administration session and store the secondary dose at a designated secured location within the service center. If clients would like to consume the secondary dose during their administration session, the licensee representative of the licensed service center may assist to retrieve the product. Clients must consume the secondary dose without assistance from the licensee representative or facilitator. If the secondary dose is not consumed, it must be returned unopened to the service center.

    Clients who would like to purchase and consume secondary doses must provide written consent prior to beginning their administration session.

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  • By signing this form, I agree to receive a secondary dose of psilocybin product during my administration session.

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  • Service Center Release and Waiver of Liability

  • This Service Center Release and Waiver of Liability (“SCRWL”) is made by the individual specified on the Signature Page of this SCRWL (referred to as “Client,” “I,” or “me”) in favor of NEST PDX, Inc., an Oregon corporation transacting business under the assumed business name Chariot, and TSSC, Inc., an Oregon corporation (collectively, “Service Center”). This SCRWL is dated effective as of the date that Client signs the Signature Page of this SCRWL.

    I acknowledge and understand that Service Center is requiring me to sign and deliver this SCRWL as a condition to NEST PDX, Inc. permitting one or more of my psilocybin facilitation service providers (collectively, my “Facilitation Service Providers”) to use Service Center’s psilocybin service center located at 1839 NW 24th Ave., Portland, Oregon (the “Licensed Premises”) for the purpose of providing psilocybin services (“Psilocybin Services”) to me during one or more preparation sessions (“Preparation Sessions”), administration sessions (“Administration Sessions”), or integration sessions (“Integrations Sessions”), in each case held in accordance with ORS Chapter 475A and OAR Chapter 333 Division 333 (collectively, the “Oregon Psilocybin Laws”).

  • 1. Risks. I am aware of the following facts, circumstances, and risks:

    (a) Potentially Dangerous Activity. I am aware that my participation in any Preparation Session, Administration Session, or Integration Session (“Session”) held at the Licensed Premises is a potentially dangerous activity that involves the risk of: (i) temporary or permanent physical or psychological injury, pain, suffering, or disability; (ii) temporary or permanent disability; or (iii) death (collectively, the
    “Risks”).

  • (b) Administration Sessions; Risks Exist Despite Precautions. If I participate in any Administration Session held at the Licensed Premises, I am aware: (i) that I will be consuming one or more psilocybin products during the Administration Session; (ii) that the consumption of psilocybin products is a potentially dangerous activity that involves the Risks; (iii) that the Risks will exist despite the fact that the psilocybin product(s) that I consume during the Administration Session comply with all applicable Oregon Psilocybin Laws; and (iv) that the Risks will exist despite the fact that: (A) I will have completed one or more Preparation Sessions with my Facilitation Service Providers; (B) I will have completed a client information form, as required by the Oregon Psilocybin Laws; (C) my Facilitation Service Providers and I will have created a safety and support plan for me, as required by the Oregon Psilocybin Laws; (D) my Facilitation Service Providers and I will have created a transportation plan for me, as required by the Oregon Psilocybin Laws; (E) various other precautions will have been taken by my Facilitation Service Providers and Service Center; and (F) my Facilitation Service Providers will have determined that I am able to participate in the Administration Session.
  • (c) Risks Exist Despite Compliance With Laws. If I participate in any Session held at the Licensed Premises, I am aware that the Risks will exist even if: (i) my Facilitation Service Providers previously complied with all applicable Oregon Psilocybin Laws; (ii) my Facilitation Service Providers comply with all applicable Oregon Psilocybin Laws during the Session; and (iii) Service Center complies with all applicable Oregon Psilocybin Laws during the Session.
  • (d) Risks May Be Compounded by Acts, Omissions, or Negligence. If I participate in any Session held at the Licensed Premises, I am aware that the Risks may result from, or be compounded by, the acts, omissions, or negligence of: (i) Service Center or any employees, independent contractors, or other agents or representatives of Service Center; (ii) my Facilitation Service Providers; (iii) any other individuals who are present during the Session; (iv) emergency responders, if I experience a medical or other emergency during the Session; or (v) any third party.

  • 2. Voluntary Assumption of Risk. Notwithstanding the Risks, I acknowledge that:

    (a) I am voluntarily participating in each Session held at the Licensed Premises; and (b) I am assuming all of the Risks that may result from each Session held at the Licensed Premises, including but not limited to any and all Risks that may result from, or be compounded by, the acts, omissions, or negligence of Service Center or any employees, independent contractors, or other agents or representatives of Service Center.

  • 3. Waiver and Release of Liability. To the fullest extent not prohibited by applicable law, I expressly waive and release Service Center and each shareholder, director, officer, member, manager, employee, independent contractor, and other agent or representative of Service Center (collectively, the “Released Parties”) from any and all claims, actions, proceedings, damages, liabilities, and expenses of every kind, whether known or unknown, resulting from or arising out of: (a) any Session held at the Licensed Premises; (b) any psilocybin products that are consumed by me during any Administration Session held at the Licensed Premises; (c) the Licensed Premises; (d) any act or omission of Service Center or any other Released Party; (e) the ordinary negligence of Service Center or any other Released Party; or (f) any act, omission, or negligence of: (1) any of my Facilitation Service Providers, including but not limited to any of my Facilitation Service Providers who determined that I was able to participate in any Administration Session held at the Licensed Premises; (3) any other individual who is present during any Session held at the Licensed Premises; (4) any emergency responder; or (5) any third party (collectively, the “Released Claims”). I covenant that I will not sue or otherwise initiate or pursue any claim, action, or proceeding of any kind against Service Center or any other Released Party with respect to, or in connection with, any Released Claim.

  • 4. Service Center Not Providing Any Psilocybin Services. I acknowledge and understand: (a) that Service Center, on the one hand, and my Facilitation Service Providers, on the other hand, are separate and distinct legal persons; (b) that Service Center has not provided, and will not be provide, any of the Psilocybin Services to me; and (c) that my Facilitation Service Providers have been, and will be, solely responsible for providing all of the Psilocybin Services to me.


    5. General. This SCRWL will be binding on me and my heirs, personal representatives, successors, and permitted assigns, and will inure to their benefit. This SCRWL may be amended only by a written document signed by Service Center and me. If a provision of this SCRWL is determined to be unenforceable in any respect, the enforceability of the provision in any other respect and of the remaining provisions of this SCRWL will not be impaired. An electronic transmission of the signature page of this SCRWL will be considered an original signature page. At the request of Service Center, I will confirm an electronically transmitted signature page by delivering an original signature page to Service Center.


    6. Governing Law. This SCRWL is governed by the laws of the State of Oregon, without giving effect to any conflict-of-law principle that would result in the laws of any other jurisdiction governing this SCRWL.


    7. Arbitration. Except as otherwise provided in this Section 7, any dispute, controversy, or claim arising out of the subject matter of this SCRWL will be settled by arbitration before a single arbitrator in Portland, Oregon. If the parties agree on an arbitrator, the arbitration will be held before the arbitrator selected by the parties. If the parties do not agree on an arbitrator, each party will designate an arbitrator and the arbitration will be held before a third arbitrator selected by the designated arbitrators. Each arbitrator will be an attorney knowledgeable in the area of business law. The arbitration will be conducted in accordance with the procedures set forth in ORS 36.600 through ORS 36.740. The resolution of any dispute, controversy, or claim as determined by the arbitrator will be binding on the parties. Judgment on the award of the arbitrator may be entered by any party in any court having jurisdiction. A party may seek from a court an order to compel arbitration, or any other interim relief or provisional remedies pending an arbitrator’s resolution of any dispute, controversy, or claim. Any such action, suit, or proceeding will be litigated in courts located in Multnomah County, Oregon. For the purposes set forth in this Section 7, each party consents and submits to the jurisdiction of any local, state, or federal court located in Multnomah County, Oregon.


    8. Attorney’s Fees. If any arbitration or litigation is instituted to interpret, enforce, or rescind this SCRWL, the prevailing party on a claim will be entitled to recover with respect to the claim, in addition to any other relief awarded, the prevailing party’s reasonable attorney's fees and other fees, costs, and expenses of every kind, including but not limited to the costs and disbursements specified in ORCP 68 A(2), incurred in connection with the arbitration, the litigation, any appeal or petition for review, the collection of any award, or the enforcement of any order, as determined by the arbitrator or court.


    9. Entire Agreement. This SCRWL contains the entire understanding of Service Center and me regarding the subject matter of this SCRWL and supersedes all prior and contemporaneous negotiations and agreements, whether written or oral, between Service Center and me with respect to the subject matter of this SCRWL.

  • SIGNATURE PAGE TO SERVICE CENTER RELEASE AND WAIVER OF LIABILITY

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