Members’ Liability Release Form

Here’s the downloadable link. And the content if that doesn’t work:

FIRST LIGHT FARM
VOLUNTEER/MEMBER INFORMATION AND LIABILITY RELEASE 2017

 Contact Information:

Volunteer/Member Name: _____________________________ Phone: _____________

Cell Phone: ________________ E-mail Address: ______________________________

Address: ___________________ City: _________________ State: ____ Zip: _______

Liability/Information Release:

As a volunteer/member at First Light Farm (FLF), I acknowledge the risks and potential for risks when working on the land and around farm equipment. However, I feel that the possible benefits to me are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against First Light Farm, and/or employees for any and all injuries and/or losses I may sustain while on the farm.

As a volunteer/member at First Light Farm, I understand that I am required to report any accident or incident to the owners of First Light Farm so that any report may be filed, if necessary.

I also agree to read, sign, and follow the membership rules posted on First Light Farm’s website with the understanding that these rules exist for the safety of everyone.

Signature: ______________________________________ Date: ___/___/____

Name/Guardian Signature (if under 18 years old)

Witness: ________________________________________

Authorization for Emergency Medical Treatment:

 In the event emergency medical aid/treatment is required due to illness or injury while being on the property of the agency, I authorize First Light Farm to secure and retain medical treatment and transportation if needed.

In Case of Emergency:

Contact: ______________________________________ Phone: ________________

Contact: ______________________________________ Phone: _________________

Physician’s Name: ______________________________________________________________

Preferred Medical Facility: ________________________________________________________

Health Insurance Co: ______________________________ Policy #: ______________

Allergies: _______________________________________   Blood Type: ___________

Signature: ______________________________________ Date: ___/___/____

Parent/Guardian Signature (if under 18 years old)

Witness: ________________________________________

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THE ENTIRE AGREEMENT AND UNDERSTAND AND AGREE TO THE RELEASE, INDEMNIFICATION AND OTHER TERMS ABOVE.

Signed this _______ day of _________________, 20__ By: ______________________

Name/Guardian Signature (if under 18 years old)

________________________________________

Printed Name

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