Select your time

Select at least one available time slot

Contact information

First name

Enter a first name

Last name

Enter a last name

Phone

Enter a phone number

Phone type
Email address

Enter a valid email address

Email type

Address

Address

Enter an address

Apartment, suite, etc. (optional)
City

Enter a city

Country/region

Enter a country

State

Enter a state

ZIP code

Enter a zip

Additional details

C:\Users\Finance\Desktop\Logos&Videos\SHO Picture.gif 

 

 

I, ___________________________________________________________________________________ 

Print Name 

 

in consideration of SafeHouse Outreach as an employee/ contractor and/or granting permission to participate in an SHO Programs, and related events and activities, I acknowledge and agree that: 

 

  1. SHO have gone to great length to comply with applicable guidelines and reduce, as much as possible, the risk of exposure to COVID-19. Despite these reasonable precautions, adherence to applicable guidelines and reliance on public health experts, substantial risk associated with COVID-19 remains. That risk includes the possibility that anyone may be exposed to or infected by COVID-19 by participating in/at SHO and that such exposure or infection may result in personal injury, illness, permanent disability and death. I assume all risks of such exposure and agree that I will not bring any claim against the releasee (as defined below) relating to any such exposure or infection. 

 

  1. There are risks inherent and while particular rules, equipment and personal discipline may reduce this risk, the risk of injury, illness, permanent disability and death does exist; 

 

  1. I knowingly and freely assume these risks, both known and unknown, even arising from the negligence of SHO, and its partners, and assume full responsibility for my participation; 

 

  1. I willingly agree to comply with the stated and customary terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will bring it to the attention of SHO, and its partners immediately;  

 

  1. I, for myself and on behalf of my heirs, assigns and personal representatives, release, indemnify, defend and hold harmless, SHO, and all of their partners, officers, employees, independent contractors, affiliates and owners and any entity associated with SafeHouse Outreach (the "Releasees") with respect to any and all injury, disability, death, or loss of damage to my person or property to the fullest extent permitted by law, whether arising from the negligence of the releasees or otherwise. 

 

  1. I have read this waiver and release of liability, fully understand its terms, and understand that I have given up rights by signing. I sign this document freely and voluntarily without any inducement. 

 

______________________________________ ______________ 

Print Name Date 

 

_______________________________________ 

Signature 

Rev. 06-01-2020 

Confirmation

Click Continue to review our terms and conditions