Salt Lake City Fire Department
Power Wheelchair Transport Consent and Release of Liability
Incident Number
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If no incident number assigned, type Public Assist
Member Completing Form
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First Name
Last Name
Responding Crew
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MRT
ME1
T1
ME2
T2
ME3
E4
ME5
Q6
ME7
ME8
T8
Q9
E10
ME11
ME12
E13
ME14
Other
Platoon
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A Platoon
B Platoon
C Platoon
Incident Date
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-
Month
-
Day
Year
Date Picker Icon
Wheelchair Owner
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First Name
Last Name
Consent and Release of Liability
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I have requested that the Salt Lake City Fire Department (“SLCFD”) assist me in the transporting of my power wheelchair. An SLCFD employee has explained to me, and I hereby acknowledge, that damage may occur to my power wheelchair as a result of such actions. In consideration for SLCFD transporting my power wheelchair per my request and on my behalf, I hereby assume all responsibility for any damage caused by SLCFD in the moving, securing and transporting of the power wheelchair and voluntarily release, forever discharge, and agree to hold harmless and indemnify Salt Lake City Corporation, its agents or employees, and all other persons or entities from any and all liability, claims, demands, actions or rights of actions, which are related to, arise out of, or are in any way connected with the transport of my power wheelchair. I hereby sign this document after full consideration and of my own free will and choice.
Owner Signature
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Pre-Transport Pictures
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The SLCFD is transporting this wheelchair on behalf of the patient who is medically unable but who would otherwise consent to transport of the wheelchair. The SLCFD is transporting the wheelchair on the condition of "implied consent" by the patient.
Post Transport Information
Transport Destination
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Name or Location
Receiving Party
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First Name
Last Name
Transfer of Possession
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I acknowledge that I have received the power wheelchair from the Salt Lake City Fire Department. The Salt Lake City Fire Department has relinquished possession of the power wheelchair to the transport destination listed above.
Receiving Party Signature
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Post-Transport Pictures
*
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Attach Photos Here
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Additional Information
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