The undersigned, being at least eighteen years of age, and in consideration for acceptance, approval and participation in the Community Emergency Response Team (CERT) Program, sponsored by (Name of Jurisdiction), do hereby agree to this wavier and release.

I recognize that the Community Emergency Response Team (CERT) Program will involve physical labor and may carry a risk of personal injury. I further recognize that there are natural and manmade hazards, environmental conditions, diseases, and other risks, which in combination with my actions can cause injury to me. I hereby agree to assume all risks which may be associated with or may result from my participation in the program, including, but not limited to, transportation to and from volunteer sites, extinguishing small fires, providing disaster medical care, (e.g. controlling bleeding, treating shock, treating sprains and fractures, opening airways, transporting patients, etc.) performing light search and rescue activities (e.g. cribbing and leveraging, victim extrication transportation, etc.) and other similar activities.

I recognize that these program activities will involve physical activity and may cause physical and emotional discomfort. I state that I am free from any known heart, or other serious health problems that could prevent me from participating in any of the activities associated with this program. I further state that I am sufficiently physically fit to participate in the activities of this program.

I recognize that if I am accepted for the program, I will be covered by the provisions of the "Utah Volunteer Government Workers ACT" (67-20 UCA), during the time that I am performing approved volunteer activities. I specifically recognize that in accordance with this act, workers compensation and medical benefits shall be the exclusive remedy for any injury that I sustain in the course and scope of my approved participation in the program. In addition, I certify that I have medical insurance to cover the cost of any emergency or other medical care that I may receive for an illness or injury, that is outside of the program related medical coverage provided through workers compensation. I certify that if I do not have medical insurance, I will be personally responsible for the cost of any emergency or other medical care that I receive that is not covered under applicable workers compensation benefits. I agree to (Name of Jurisdiction) its agencies, departments, officers, employees, agents, and all sponsors and/or officials and staff from any said entity or person, their representatives, agents, affiliates, directors, servants, volunteers, and employees from the cost of any medical care that I receive while participating in this program or as a result of it.

I further agree to release (Name of Jurisdiction), its agencies, departments, officers, employees, agents, (entity and persons as appropriate) and all sponsors and/or officials and staff of any said entity or person, their representatives, agents, affiliates, directors, servants, volunteers and employees from any and all liability, claims, demands, actions, and causes of actions whatsoever for any loss claim, damage, injury, illness, attorney's fees or harm of any kind or nature to me arising out of any and all activities associated with the aforementioned activities.

I further agree to hold harmless, and hereby release the above mentioned entities and persons from all liability, negligence, or breach of warranty associated with injuries or damages from any claim by me, my family, estate, heirs, or assigns from or in any way connected with the aforementioned activities.

CONSENT

Consent is expressly given, in the event of injury, for any emergency medical aid, anesthesia, and/or operation, if in the opinion of the attending physician, such treatment is necessary.

I HAVE CAREFULLY READ AND UNDERSTAND THE CONTENTS OF THE FOREGOING LANGUAGE AND I SPECIFICALLY INTEND IT TO COVER ANY PARTICIPATION IN THE COMMUNITY EMERGENCY RESPONSE TEAM PROGRAM SPONSORED BY (NAME OF JURISDICTION).

NAME ___________________________ DATE ______________

SIGNATURE ____________________________