Kaiser Permanente1 Volunteer Release

Name of Adult Participant:

1

Kaiser Permanente

Volunteer Release

Name(s) of Minor Participant(s):

Event: Kaiser Permanente Hawaii Annual Day of Service –

1.

Hosted by HPMG

2.

Date of Activity: 1/18/16

3.

Part I – General Terms and Conditions; Release and Waiver of Liability

Part III – Dengue Fever Alert (Hawaii Island only)

I understand the nature of this Event and represent that I am qualified, in

Pu'u Wa'awa'a Forest Reserve is in an area where there is a potential for

good health, and in proper physical condition to participate in such Event. I

dengue infection (also known as dengue fever). Dengue is a mosquito borne

understand that this Event may involve risk of injury, including the possibility

virus that causes fever, rash, headaches and body aches. It is uncommon

of serious bodily injury, including permanent disability, paralysis and death,

here in Hawaii; the current outbreak on Hawaii Island is the third in the state

which may be caused by the nature of the Event, my own actions or

over the past 15 years. The infection usually resolves within a couple of

inactions, those of others participating in the event, the conditions in which

weeks, but sometimes people with dengue have blood clotting problems,

the Event takes place, or the negligence of the "Releasees" named below. I

which can lead to bleeding and shock. When this happens it is called severe

acknowledge that if I believe Event conditions are unsafe, I will immediately

dengue. There is no vaccine to prevent dengue; therefore, while you are

discontinue participation in the Event. I understand that there may be other

volunteering at Pu'u Wa'awa'a Forest Reserve we recommend that you

risks either not known to me or not readily foreseeable at this time and I fully

follow the mosquito precautions listed below:

accept and assume all such risks and all responsibility of injury, losses,

1. Wear long-sleeved shirts and pants or long skirts if possible. 2. Apply

costs and damages that I may incur as a result of my participation in the

mosquito repellent to exposed skin. Effective repellents available at Kaiser

Event.

Permanente pharmacies include 20% DEET. This is effective for up to

I hereby release, discharge, and covenant not to sue all of the following:

several hours but should be reapplied if there is excessive sweating or water

Kaiser Permanente (including Kaiser Foundation Health Plan, Kaiser

exposure. (We will provide mosquito repellent at the volunteer site.) 3. For

Foundation Hospitals and the Hawaii Permanente Medical Group, Inc.),

those who desire additional protection, permethrin can be applied to clothes.

Papahana Kuaola, Kāko‘o ‘Ōiwi, Paepae O He‘eia, Ka‘ala Farm, and each of

Permethrin spray is available over-the-counter at most Kaiser Permanente

their respective administrators, directors, agents, officers, affiliates,

pharmacies. Clothes treated with permethrin retain their efficacy even after

volunteers and employees, as well as other participants, and sponsors,

several washings. 4. If using both sunscreen and mosquito repellent, apply

advertisers, and, if applicable, owners and lessors of premises on which the

the sunscreen first and then the repellent. Please note that products

Event takes place, (all of whom are individually and collectively referred to

combining sunscreen and repellent are not recommended. 5. "Natural"

herein as "Releasees") from all liability, claims, demands, losses, or

products such as citronella, essential oils, garlic, and B vitamins are not

damages, on my account caused or alleged to be caused in whole or in part

effective in warding off mosquitoes. 6. Participants should seek medical

by the negligence of the Releasees, or otherwise, including negligent rescue

attention for any fever that occurs within 2 weeks of the event.

operations, and future agree that if, despite this release, waiver of liability,

Part IV – Applicable to Kaiser Permanente (KP) Employees Only

and assumption of risk I, or anyone on my behalf, makes a claim against any

I acknowledge that my participation in this event or activity is entirely

of the Releasees, I will indemnify, save and hold harmless each of the

voluntary, with no coercion by KP, no promise of advancement, and no

Releasees from any loss, liability, damage, or cost, which any may incur as

penalty for not volunteering. I have not been promised nor do I expect

the result of such claim.

compensation from KP for my services. I recognize that my volunteer

I have read this RELEASE AND WAIVER OF LIABILITY provision and

services are not within the course and scope of my employment with KP, are

understand that I have given up substantial rights by signing it and have

different from my regular KP work duties and are being performed on a

signed it freely and without an inducement or assurance of any nature and

voluntary basis outside of my normal work hours. My volunteer services are

intend it to be a complete and unconditional release of all liability to the

for charitable or humanitarian objectives as well as for my personal purpose

greatest extend allowed by law and agree that if any portion of this

or pleasure. KP or I may discontinue my service as a volunteer at any time,

agreement is held to be invalid the balance, notwithstanding, shall continue

with or without cause and without prior notice.

in full force and effect. As the custodial Parent and/or lawful Guardian of the

Part V – Photo/Video Release

child or children referenced in this release I understand and agree to the

I, the undersigned, hereby irrevocably consent to the unrestricted use for or

above for my child or children.

by Kaiser Permanente and its affiliates and their respective directors,

officers, employees, agents, customers, successors and assigns (collectively

Part II – Leptospirosis Alert (Oahu only)

While you are working in the He`eia (Windward Oahu) or Waianae (Leeward

“KP”), as well as cooperating organizations involved with the Annual Day of

Oahu) Watershed environments, there is a chance of exposure to the germ

Service, of any and all video and photographs taken of me today and all

that causes leptospirosis, a water-borne infection, that is often mild, but can

images created there from. Scope of Consent. KP may use my name and

occasionally be dangerous and may lead to more serious consequences,

such photographs and images for any and all purposes, including art,

including temporary or permanent impairment of liver and kidney function

advertising, promotional, educational, and web, and in all media, including

and, in some cases can also result in death. Though the actual risk of

electronic, digital, and print media, without further compensation to me. I

contracting leptospirosis during work in the water in the He`eia or Waianae

certify that I am not a minor and am free and able to give such consent.

Watersheds is likely low, please wear appropriate clothing and foot attire

Term. The term of this consent shall be perpetual. Waiver. I waive any right

while working in the water or in the taro patch. Protect your skin from cuts

to approve: 1) the finished video, photographs, images, or printed matter that

and scrapes, and do not immerse any open wounds or skin rashes

may be used in connection with my name or the photographs taken of me;

underwater. Seek medical attention promptly if you develop a significant

and 2) the eventual use of any of the foregoing. I acknowledge that KFHP

illness or fever within two weeks after your day of participation at the He`eia

owns all rights in these photographs and I waive any claims that I have or

or Waianae Watersheds.

may have based on their usage of the photographs or works derived there

from. Release. I hereby release and hold harmless KP and any

A one-time dose of an antibiotic taken on the Day of Service can help to

photographers or videographers from all damages and liability that may arise

protect you from acquiring leptospirosis. If you are interested in taking an

from or in connection with the use of my name, the photographs or video

antibiotic for leptospirosis prevention on the Day of Service, please contact

images taken of me, or the images created there from. Entire Agreement.

Dr. Johnnie Yates at . Please note that there will be

This agreement constitutes the sole agreement between KP and myself, and

many opportunities for volunteering at He`eia and The Cultural Learning

I am not relying on any other oral or written representations made by KP.

Center at Ka‘ala Farm that do not involve working in the water, for those who

would prefer this.

I have read, understand and agree with all of the foregoing.

Adult Signature __________________________________________________________

Date _____________________

As the custodial Parent and/or lawful Guardian of the child or children referenced in this document I also indicate by my signature above that I understand and agree to the above for my child or children.

Address:

Email:

Phone:

1

Kaiser Permanente is a registered trade name and for purposes of this document collectively refers to Kaiser Foundation Health Plan, Kaiser Foundation Hospitals and the

Hawaii Permanente Medical Group, Inc.