Missouri Shores Domestic Violence Center

RELEASE FROM LIABILITY

In consideration of accepting services from Missouri Shores Domestic Violence Center (MSDVC), I _____________________________________ hereby release MSDVC, its owners, shelter, staff and volunteers from any and all liability, claims, demands, action, causes of action, whatsoever, arising out of or related to any loss, damages, or injury, including death, that may be sustained by me (and/or my child(ren) ______________________________________________ ________________________________ while receiving services from MSDVC in, on or upon the premises of MSDVC, in or upon the premises of other locations sponsored by MSDVC, or while in any vehicle being driven by a staff member, volunteer, or an outside contract source of MSDVC.

I am aware of the risks and hazards inherent in entering the premises of the MSDVC shelter or other MSDVC lodging arrangements, and of being a passenger in a vehicle driven by the MSDVC staff or volunteers.  With this awareness I have voluntarily elected to remain on the premises of MSDVC shelter or participate in other MSDVC events, and to be transported in vehicles driven by MSDVC staff, volunteers, or an outside contract source (and to allow my child(ren)) to remain on the premises of MSDVC shelter or where MSDVC events are taking place, and to be transported in vehicles driven by MSDVC staff,  volunteers or and outside contract source.

This release shall be binding on my heirs, next of kin, executors, and administrators.

In signing the foregoing release, I acknowledge that:

(A)    The terms of this release are contractual and not a mere recital.

(B)     I have read the foregoing release, and understand it, and sign it of my own free will.

(C)     I am of sound mind.  Though I may be under emotional stress, I understand the above release of liability.

CAUTION:  THIS IS A RELEASE, READ BEFORE SIGNING

This release executed on the ______ day of _________________, 20____.

                                                            _______________________________________

                                                            Client Signature/Date

                                                            _______________________________________

                                                            Advocate/Staff Signature/Date

Revised 5Aug2008-Hilary Fenske

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Updated 30 August 2010

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