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Wellness Check Waiver

The Wellness Check Waiver along with a completed application must be on file to be a part of this program. Complete the waiver below.

Online Application

Name
I fully understand that my participation in the City of Mission Viejo Voluntary Wellness Check Program (hereinafter "program") exposes me to the risk of personal injury, death, communicable diseases, illnesses, viruses, or property damage/loss. I hereby acknowledge that I am voluntarily participating in this program and agree to assume any such risks.

I hereby release, discharge and agree not to sue the City of Mission Viejo and the Community Emergency Preparedness Academy (hereafter “CEPA”) for any injury, death or damage to or loss of personal property arising out of, or in connection with, my participation in the program from whatever cause, including the active or passive negligence of the City of Mission Viejo, CEPA or any other participants in the program. The parties to this AGREEMENT understand that this document is not intended to release any party from any act or omission of “gross negligence,” as that term is used in applicable case law and/or statutory provision.

In consideration for being permitted to participate in the program, I hereby agree, for myself, my heirs, administrators, executors and assigns, that I shall indemnify and hold harmless the City of Mission Viejo, CEPA, and their respective officers, officials, employees, agents, and volunteers from any and all claims, demands actions or suits arising out of or in connection with my participation in the program.

I HAVE CAREFULLY READ THIS RELEASE, HOLD HARMLESS AND AGREEMENT NOT TO SUE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY AND SIGN IT ON MY OWN FREE WILL.
Full Name
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