HO’ONANI PLACE,LLC
dba Ho'oNani Day Center
Waiver and Release
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Please Print Participant’s Name
In consideration of my acceptance as a participant in the adult day care programs and services offered by Ho’oNani Place, LLC, I, the undersigned, for myself, my heirs, personal representatives, estates, administrators and assigns, hereby waive and release any and all claims for damages, for death, personal injury, loss of property or property damage I may have, or that may subsequently accrue to me, or to my heirs, personal representatives, estates, executors, administrators or assigns, against Ho’oNani Place, LLC, its officers, owners, managers, members, employees, agents, representatives and staff, including any unpaid volunteers, arising from or as a result of my participation in such programs and/or my receipt of any such services provided by Ho’oNani Place, LLC, its employees, representatives, staff and/or unpaid volunteers.
I acknowledge that as a result of the limitations in my ability to care for myself without assistance, my care and custody, and my participation in various activities, involves known and unknown risks of accidents and injuries as a result of the acts, conduct and/or omissions of other participants and/or the employees, staff and/or volunteers of Ho’oNani Place, LLC. Knowing such risks and agree to indemnify, release and hold harmless all of the persons and entities described above who may or might be liable to me (or my heirs, personal representatives, estates or assigns) for damages. My participation in the adult day care programs and services offered and provided by Ho’oNani Place, LLC, is voluntary and done at my own risk.
I hereby consent to receive medical treatment which may be deemed advisable in the event of my injury, accident or illness while at Ho’oNani Place, LLC, but I understand and agree, however, that medical or other services rendered to me by, or at the instance of, any of the persons or entities described above is not an admission of liability to provide waiver by any or the persons or entities described above of any rights under this Waiver and Release.
I agree to accept and abide by the rules and policies of Ho’oNani Place, LLC, as established and provided to me from time to time.
I have read this Waiver and Release and fully understand its contents. I am aware this Waiver and Release is a release of liability and a contract between myself and Ho’oNani Place, LLC, for the benefit of the persons and entities described above and I voluntarily sign this Waiver and Release of my own free will.
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Signature of ParticipantDate
IF THE PARTICIPANT IS UNDER THE CARE OF CUSTODY OF A GUARDIAN, THE SIGNATURE OF THE GUARDIAN OF THE PARTICIPANT IS REQUIRED.
GUARDIAN WAIVER
I undersigned Guardian of the participant named above hereby represents that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnity each and all of the persons and entities described above from all liability, losses, costs, claims or damages whatsoever which may be imposed upon said persons and entities because of any defect in or lack of such capacity to so act and release and discharge said persons and entities as above stated on behalf of the participant named below.
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Signature of GuardianDate
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