Member Agreement/Waiver of Liability
I hereby certify that all information I have supplied in this membership application is true, complete and accurate. I understand that by submitting this membership application, I authorize inquiries to be made concerning my suitability as a member, and that this application is not a guarantee that I will be accepted as a member of King Farm Neighbors Village and Senior Rides.
I hereby affirm that I meet all minimum requirements for the program(s) I am applying for and have supplied such additional information as required. I agree to comply with and be bound by the policies of the program. Furthermore, I agree that King Farm Neighbors Village and/or Senior Rides may, for publicity purpose use my image and/or any comment or quotation made by me.
I understand that King Farm Neighbors Village and/or Senior Rides may collect medical information from me that may include diagnosis, symptoms, treatments, doctor visits or other similar information. Any such information provided is strictly confidential and will not be disclosed or used for any purpose other than providing services as requested herein.
I understand and agree that for any service performed for me which includes any period that I am under general anesthesia (or similar), it will be my sole responsibility to have assistance available for me by a third party. Any responsibility of King Farm Neighbors Village and/or Senior rides, its staff and volunteers ends when the scheduled transportation appointment is concluded and I am delivered to my residence.
I hereby release, waive, indemnify and hold harmless King Farm Neighbors Village and/or Senior Rides, its Directors, Officers, employees and volunteers from any and all loss, damages or liability including personal injury or death arising from my voluntary participation in the program(s) to which I have applied. I further agree that this Membership Application and Waiver of Liability is intended to be as broad and inclusive as is permitted by the laws of the State of Maryland, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I have read and voluntarily sign the Membership Application and Waiver of Liability. I do so recognizing that I have been advised by King Farm Neighbors Village and Senior Rides that I have the right to consult with my own legal counsel concerning the Membership Application and Waiver of Liability for clarification of any of the terms contained herein. I further agree that no oral representations, statements or inducements, apart from the foregoing written agreement, have been made.