Respite Support

Please note: We are currently only able to support Respite services for individuals that speak fluent english

Releaase and Waiver of Liability Agreement

PossAbility Unlimited (the “Company”) and in his/her individual capacity (the “Caregiver”) provide respite care services (the “Activity”) and is willing to permit the individuals (the “Participants”) signing this Agreement to participate in the Activity, upon the terms and conditions of this Agreement. In consideration for being provided the ability to participate in the Activity, each person signing below hereby stipulates and agrees:

1. Assumption of Risk. I understand and acknowledge that I risk exposure to and contraction of potentially dangerous diseases and viruses by participating in the Activity. I understand and acknowledge the risks associated with diseases and viruses and I am fully aware that exposure may result in infection, severe illness, injury, pain and suffering, temporary or permanent disability, and even death. I further acknowledge that any exposure I may sustain while participating in the Activity may be compounded by negligent or delayed medical service or negligent or delayed assistance by the Company or the Caregiver. I voluntarily and freely assume all risks and dangers that may occur pursuant to my participation in the Activity.
2. Release from Liability. I hereby RELEASE, WAIVE, and DISCHARGE the Company, the Caregiver, the Caregiver’s household members, the Company’s affiliates, employees, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (the “Releasees”) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury that I may sustain before, during or after my participation in the Activity. I further agree not to sue the Releasees or initiate or assist in the prosecution of nay claims for damages or cause of action against the Releasees which I may have as a result of any personal injury, death, or property damage I may sustain while participating in the Activity.
3. Indemnification. I hereby agree to defend, indemnify and hold harmless Company, the Caregiver, and the Releasees from and against any third-party losses, damages, actions, suits, claims, judgments, settlements, awards, interest, penalties, expenses (including reasonable attorneys’ fees) and costs of any kind for any infection, illness, personal injury, loss of life or damage to property sustained by reason of or arising out of my participation in the Activity.
4. Medical Treatment Release. I hereby authorize the Company or the Caregiver to secure, and I consent to, any medical treatment that may be given to me should the Company and the Caregiver determine, in its sole discretion, that I need medical care, as a result of my participation in the Activity. I accept full responsibility for all costs related to my medical treatment, including any transport costs, and I release all Parties involved from any type of liability for anything that may happen during my treatment or transport.
5. Responsibility for Personal Property. I acknowledge and agree that I am fully and solely responsible for any of my property and personal belongings that I use during the Activity, and that the Company and the Caregiver will not be responsible for or provide any security for my property and personal belongings.
6. Transportation. I acknowledge that in connection with the Activity, the Company or the Caregiver may provide transportation services to me (“Transportation Services”). At all times during my participation in the Transportation Services, I will properly utilize all recommended safety equipment and follow all recommended instructions and procedures pertaining to the Transportation Services, including, but not limited to, abiding by all applicable laws regarding vehicular travel. I acknowledge that the Company and the Caregiver are not a common carrier or a provider of transportation services to the public, and that the Company, the Caregiver and any of their employees, including any drivers, are not skilled at, or provided training on, any of my individual transportation and medical needs, including the loading or unloading of my person and belongings. Such Transportation Services shall be considered shall be considered part of the Activity and as such, all releases contained in this Release and Waiver shall be applicable to any Transportation Services.
7. No Representations by Company/Caregiver. I acknowledge that Company and the Caregiver make no representation as to the safety of the Activity. I acknowledge and agree that I am not relying upon any representation or statement by the Company, the Caregiver, or the Company’s employees, agents, sponsors, or representatives regarding this Agreement or the Activity, except to the extent such representations are expressly set forth in this Agreement.
8. Personal Representations. I represent that I will comply with all directives given by the Company and the Caregiver, whether in print or orally, in all matters. I represent that I am aware of government laws, orders and guidelines that relate to diseases and viruses and will abide by all those laws, orders and guidelines.
9. Waiver. No waiver of any term or right in this Release and Waiver of Liability agreement shall be effective unless in writing, signed by an authorized representative of the waiving party. The failure of any party to enforce any provision of this Agreement shall not be construed as a waiver or modification of such provision, or impairment of its right to enforce such provision or any other provision of this Agreement thereafter.
10. Severability. If any provision or portion of this Release and Waiver of Liability agreement shall be held by a court of competent jurisdiction to be illegal, invalid, or unenforceable, the remaining provisions or portions shall remain in full force and effect.
11. Governing Law: This Release and Waiver of Liability will be governed by and interpreted in accordance with the laws of the State of Indiana, without giving effect to the principles of conflicts of law of such state.
12. Entire Agreement; Binding Effect: This Agreement is the entire agreement between the Parties with respect to the subject matter hereof and supersedes any prior agreement or communications between the Parties, whether written, oral, electronic, or otherwise. This Agreement shall be binding upon and inure to the benefit of the successors, assigns, and legal representatives of the Parties.
13. Acknowledgement. I acknowledge that by executing this Release and Waiver of Liability, I am giving up considerable future legal rights. I execute this Release and Waiver of Liability freely, voluntarily, under no duress or threat of duress, without inducement promise, or guarantee being communicated to me.

PossAbility Unlimited Medical Informed Consent

1. This form is called in “Informed Consent Form”. It is your health care provider’s obligation to provide you with information you need in order to decide whether to consent to medical treatment or medical procedure that your health care provider(s) have recommended. The purpose of this form is to verify that you have received this information and have given your consent to the medical treatment and/or medical procedure recommended to you. You should read this form carefully and ask questions of your health care provider(s) so that you fully understand the medical treatment or medical procedure before you decide whether or not to give your consent. If you have questions, you are encouraged and expected to ask them before you sign this Informed Consent Form. Your health care provider(s) are not employees or agents of PossAbility Unlimited. They are independent health care providers.

2. Your health care provider(s) have recommended the following medical treatment(s) or medical procedure(s):

• Catheterization
• Bowel Procedure
• Medication Procedure
• Skin Assessment (Full Body)
• Physical Assistance (including, but not limited to, bathing assistance, toilet use assistance, and feeding assistance)
• Education & Individual Personal Care Instruction (Male & Female Patient)

Upon your authorization and consent, the above medical treatment(s) or medical procedure(s), together with any different or further treatment or procedures which, in the opinion of the health care provider(s) performing the treatment or procedure, may be indicated due to an emergency or newly-discovered information, will be performed on you. The medical treatment or medical procedure will be performed by the health care provider(s) named below (or, in the event the health care provider is unable to perform or complete the medical treatment or medical procedure, a qualified substitute health care provider), together with associates and assistants, including licensed registered nursing staff and volunteer staff, to whom the physician performing the medical treatment or medical procedure may assign designated responsibilities.

3. Name of health care provider(s) who is performing the medical treatment or medical procedure: PossAbility medical team; Lauren Harmison, FNP-BC

PossAbility Unlimited maintains personnel and facilities to assist your health care provider(s) in their performance of various medical treatments and medical procedures. However, your health care provider(s), including licensed registered nursing staff, and volunteers in attendance for the purpose of performing medical treatment or medical procedures are not employees, representatives or agents of PossAbility Unlimited. They are independent health care providers.

4. All medical treatments and medical procedures carry the risk of unsuccessful results, complications, injury or even death, from both known and unknown causes, and no warranty or guarantee is made as to result or cure. You have the right to be informed of:

1. The nature of the medical treatment or medical procedures, including other care, treatment or medications;
2. Potential benefits, risks or side effects of the medical treatment or medical procedure, including potential problems that might occur;
3. The likelihood of achieving treatment goals;
4. Reasonable alternatives and the relevant risks, benefits and side effects related to such alternatives including the possible results of not receiving care or treatment; and
5. Any independent medical research or significant economic interest your physician may have related to the performance of the proposed medical treatment or medical procedure.

Except in cases of emergency, medical treatment or medical procedures are not performed until you have had the opportunity to receive this information and have given your consent. You have the right to give or refuse consent to any proposed medical treatment or medical procedure at any time prior to its performance.

5. Your signature on this Informed Consent Form indicates that:

1. You have read and understand the information provided on this form;
2. Your health care provider has adequately explained to you the medical treatment or medical procedure set forth above, along with the risks, benefits, and other information described in this Informed Consent Form;
3. You have had a chance to ask your health care provider questions;
4. You have received all of the information you desire concerning the medical treatment or medical procedure; and
5. You authorize and expressly consent to the performance of the medical treatment or medical procedure.

PossAbility Unlimited will communicate with you via email, SMS text messaging, and/or via direct messaging applications. The information sent via these channels may not be encrypted. This means that a third party may be able to access the information and read it as it is transmitted over the internet.

Your signature on this form indicates that:

1. You understand and have been made aware of the risks of sending and receiving my personal health information via email, SMS text messages, and direct messaging applications;
2. You consent to receive communication via email, SMS text messages, and direct messaging applications; and
3. You release PossAbility Unlimited from any liability related to unauthorized access, disclosure, or interception of your information that may occur.