Safety First Contact Form (Page 2 of 2) in pdf

_______________________________________________

Please list any special needs (walker, etc.):

Do you have a “Do Not Resuscitate” (DNR)?

Yes

Location of DNR (i.e., which Physician, Hospital, or Person/s):

__________________________________________

_________________________________________________________________________________________________

DNR Contact Phone: _______________________________

Signature:

_______________________________________________________________________________

Authorizes use of this information for emergency purposes ONLY

Program Participant Waiver

I, ______________________________, voluntarily, make and grant this waiver in favor of the LIFESPAN

Resources, Inc., and all partners, affiliates and participating agencies, including but not limited to Trinity

Presbyterian Church.

I do herby waive and release any and all claims whether in personal injury, damages, or losses that may arise

from trips taken or services provided to me through any and all of the LIFESPAN Resources, Inc. service

provider participants. I understand that LIFESPAN Resources, Inc. neither recommends nor endorses any of

the participating providers.

I further agree to use my best judgment and to adhere to all safety instructions and recommendations from

any of the providers. I herby certify that I am a competent adult participating in this program of my own free

will.

I have read and agree to the terms and conditions printed on this Waiver and Assumption Risk form. This

waiver will remain in effect as long as I am a participant in any of LIFESPAN Resources, Inc. programs or

activities.

Date: _______________________________

Name: _________________________________________________

Please Print

Signature:

_____________________________________________________________________________

Return to:

LIFESPAN Resources, 3003 Howell Mill Rd NW, Atlanta, GA 30327, 404-237-7307

All information will be maintained in confidence.

July, 2015

Safety First Contact Form Page 2