BTG's Uber Transportation - Liability Waiver Form

Date*

Date

Client Name*

First NameLast Name

Client Phone Number*

Please enter a valid phone number.

Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Email*

example@example.com

Parent / Caregiver Name (if Client is a minor)

First NameLast Name

Permissions:*

I am the Individual, Parent, Caregiver mentioned above.I understand that every effort will be made to protect the well-being of all clients, Parent, Caregiver receiving transportation services via Uber Rideshare, but I agree in case of accidental injury, I will NOT hold the Bridging The Gap - Adult Sickle Cell Disease Foundation of Nevada and its leaders, directors, officers, employees, contractors, agents, volunteers, members and representatives (collectively referred to as “Bridging The Gap - Adult Sickle Cell Disease Foundation of Nevada or/ BTG”) harmless and therefore are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, activities or travel with the BTG and all related activities associated with the BTG, including injury, loss or damage. The BTG policy is that participants will not bring the following substances: alcohol, drugs, nicotine, or weapons (including pocket knives, guns, and ammunition) or participate in physical relationships during any transportation services provided by the BTG. Violation of this policy will result in any current and/or future Uber Rideshare transportation request to be denied.I agree to utilize the BTG's UBER Rideshare services for transportation to and from appointments pertinent to BTG services.I acknowlege that the BTG Staff is not responsible for any trip cancelled by Uber during my travel.I understand that the BTG is not responsible for any missed medical appointment due to a technical malfunction in the Uber ride system and/ or delay caused by the Uber driver.I agree that BTG will not continue to pay for rides for me if I have failed to cancel my Uber Rideshare prior to the ride being dispersed and/or I am late more than 2 times, as BTG is incurring cancellation and wait time fees.I understand that BTG's Uber Rideshare is not a long- term transportation service and will work with my assigned Community Health Worker to assist in a permanent transportation plan.I understand that BTG's Uber Rideshare is not a guaranteed service or an entitlement.I understand that BTG will not schedule an Uber Rideshare unless and until BTG has received this signed Waiver Form. BTG will maintain this form for one (1) year.

I understand that by filling out this consent form, I waive all liability from BTG while utilizing the Uber Rideshare program.

I understand that I can withdraw consent at any time by contacting my Community Health Worker.

Withdrawal of consent means that you WILL NOT utilize the BTG's Uber Rideshare service.

Signature

Uber Transportation/Liability Waiver Form