ELLINGTON VOLUNTEER AMBULANCE CORPS Observer Waiver Form LAST NAME FIRST NAME MIDDLE NAMI Home Address 1 (physical) Home Address 2 (PO Box/Alt.) Town State Zip Code Phone Number List anymedical training you have. Emergency Contact Name Phone Number Date/Time of Scheduled Observation Time 1 2 3 r.i'a. -o Check one n Al least 18years of age n'l4to 17 years of age(if checked, complete the information below) ParenUGuardian Information LASTNAME FIRST NAME MIDDLE NAMI Home Address 1 (physical) Home Addrcss 2 (PO Bor/Alt.) Town State Zip Code Phone Number By signing below: Relationship to observer? I understand that observing and riding with an emergency ambulance crEw has inherent risksincluding, but not limited to possible exposure to serious diseases, violent patient behavior, highspeed travel, potentially disturbing experiences involving blood, vomitand bodily deformities. An observer safety vest is available and mustbe worn at all timesduring the observation experience with EVAC. I understand that I am limited to observe three,approved and prescheduled shifts withcalls. ll no calls are observed during theseshifts, additional observation time will be granted as necessary. I understand that the Ellington Volunteer Ambulance Corpe crewmayat anytime and placedismiss me from the ambulance in the interest of safety of the patient and/or me. I understand that if I am dismissed, I am responsible for my owntransportation. I agree that I will not holdthe Ellington Volunteer Ambulance Corps, officers of the Ellington Volunteer Ambulance Corps, members or employees of the Ellington Volunteer Ambulance Corps,or the ambulance crewliable for personal injury, property loss,mental or emotional distrgss, or any othercircumstance or situation during the observation experience. I understand that patient privacy is protected by Connecticut State Statue and Federal Law (HIPAA). Disclosure of protected personal patient information maylead to jail timeand up to $10,000 in fines. agrees thatit willindemnify, defend andsaveharmless the Ellington Volunteer Ambulance Corps andall agents, servants andemployees, departments, boards, commissions, and agencies regardless of their negligence, from all liability arising or,rt of property damages or physical injury or death to all persons participating in the Observer Program as described above. Signature of Observer (or minor's parenUguardian) DateObserver waiversigned Date Approved EVAC Approved Signature (Executive Board Officer) CREW ACCEPTANCE (Circle one): YES NO fi-ffi.i-rl.1r_s - EvAc o n I y

fi-ffi.i-rl.1r s - Ellington Volunteer Ambulance Corps ... · Ambulance Corps, members or employees of the Ellington Volunteer Ambulance Corps, or the ambulance crew liable for personal

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Page 1: fi-ffi.i-rl.1r s - Ellington Volunteer Ambulance Corps ... · Ambulance Corps, members or employees of the Ellington Volunteer Ambulance Corps, or the ambulance crew liable for personal

ELLINGTON VOLUNTEER AMBULANCE CORPSObserver Waiver Form

LAST NAME FIRST NAME MIDDLE NAMI

Home Address 1 (physical) Home Address 2 (PO Box/Alt.) Town State Zip Code

Phone Number List any medical training you have.

Emergency Contact Name Phone Number Date/Time of Scheduled Observation Time 1 2 3 r.i'a. -o

Check one n Al least 18 years of agen'l4to 17 years of age (if checked, complete the information below)

ParenUGuardian Information

LAST NAME FIRST NAME MIDDLE NAMI

Home Address 1 (physical) Home Addrcss 2 (PO Bor/Alt.) Town State Zip Code

Phone Number

By signing below:

Relationship to observer?

I understand that observing and riding with an emergency ambulance crEw has inherent risks including, but notlimited to possible exposure to serious diseases, violent patient behavior, high speed travel, potentiallydisturbing experiences involving blood, vomit and bodily deformities. An observer safety vest is available andmust be worn at all times during the observation experience with EVAC. I understand that I am limited toobserve three, approved and prescheduled shifts with calls. ll no calls are observed during these shifts,additional observation time will be granted as necessary.

I understand that the Ellington Volunteer Ambulance Corpe crew may at anytime and place dismiss me fromthe ambulance in the interest of safety of the patient and/or me. I understand that if I am dismissed, I amresponsible for my own transportation.

I agree that I will not hold the Ellington Volunteer Ambulance Corps, officers of the Ellington VolunteerAmbulance Corps, members or employees of the Ellington Volunteer Ambulance Corps, or the ambulancecrew liable for personal injury, property loss, mental or emotional distrgss, or any other circumstance orsituation during the observation experience.

I understand that patient privacy is protected by Connecticut State Statue and Federal Law (HIPAA).Disclosure of protected personal patient information may lead to jail time and up to $10,000 in fines.

agrees that it will indemnify, defend and save harmless the EllingtonVolunteer Ambulance Corps and all agents, servants and employees, departments, boards, commissions, andagencies regardless of their negligence, from all liability arising or,rt of property damages or physical injury ordeath to all persons participating in the Observer Program as described above.

Signature of Observer (or minor's parenUguardian) Date Observer waiver signed

Date ApprovedEVAC Approved Signature (Executive Board Officer)

CREW ACCEPTANCE (Circle one): YES NO fi-ffi.i-rl.1r_s - EvAc o n I y