BTG's Uber Transportation - Liability Waiver Form

Uber Transportation/Liability Waiver Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name

First NameLast Name
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 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 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
Should be Empty:

Uber Transportation/Liability Waiver Form