TEAM GLEASON FOUNDATION

LIABILITY WAIVER AND RELEASE AGREEMENT

Waiver and Release. I, the undersigned, voluntarily agree to participate in the below-described event(s) and/or program(s) of the Team Gleason Foundation, a Louisiana Non-Profit Corporation (hereinafter “Team Gleason”). Such event(s) and/or program(s) may include, but are not limited to: adventures, home renovations, home automations, respite care, voice banking, loaner equipment, and other technologies as may be amended from time to time.

I recognize that Team Gleason has not undertaken any duty or responsibility for my safety and I agree to assume full responsibility for all risk of bodily injury, death, disability, loss and/or property damage as a result of participating in any Team Gleason event(s) and/or program(s). I knowingly and freely accept any and all risks encountered while participating in any and all Team Gleason event(s) and/or program(s) and hereby release Team Gleason and its directors, board members, employees, independent contractors, agents, volunteers, assignees, delegates, and any other agents (the “Released Parties”) from any and all liability arising therefrom. I further surrender any right to seek reimbursement from the Released Parties for any and all injuries I may sustain and/or any and all liability that I may incur during my participation in any Team Gleason event(s) and/or program(s).

I, my heirs, executors, administrators and representatives, do hereby agree to and will indemnify, absolve, and hold harmless the Released Parties from any and all claims brought against the Released Parties that may arise out of my conduct in connection with any and all Team Gleason event(s) and/or program(s). Said indemnity shall include all amounts of damages, interest, costs, penalties, and the like that may be cast upon the Released Parties and any and all attorney’s fees incurred in connection with the defense of any and all claims brought against the Released Parties in connection with the aforementioned conduct.

I further recognize that the Released Parties will not provide medical, health, and/or disability insurance coverage to me in connection with any Team Gleason event(s) and/or program(s).

Loaned Equipment. I further recognize and agree that Team Gleason and its affiliates, sponsors, and vendors may, at their discretion and from time to time, provide loaned equipment to me. I agree that it is my (or legal guarantor) responsibility to see that the equipment is properly maintained and to seek repairs when necessary. Companies that manufacture assistive technology and equipment provide warranties specific to the product, and if the company should require registration of the equipment provided by Team Gleason in order to activate the warranty of said equipment, it is my (or legal guarantor) responsibility to do so. I am aware of, understand, and consent and agree to the policies concerning any warranty provided by the manufacturer as it relates to the specific equipment provided. Equipment provided by Team Gleason remains the sole property of Team Gleason and is to be returned when no longer being used by myself (so that it may be distributed to another individual in need). Team Gleason will assume the shipping costs associated with the return. To arrange the return, please contact returns@teamgleason.org.

Purchased Equipment. I further recognize and agree that Team Gleason and its affiliates, sponsors, and vendors may, at their discretion and from time to time, provide purchased equipment to me. I agree that it is my (or legal guarantor) responsibility to see that the equipment is properly maintained and to pay for all repairs when necessary. Companies that manufacture assistive technology and equipment provide warranties specific to the product, and if the company should require registration of the equipment provided by Team Gleason in order to activate the warranty of said equipment, it is my (or legal guarantor) responsibility to do so. I am aware of, understand, and consent and agree to the policies concerning any warranty provided by the manufacturer as it relates to the specific equipment provided.

Protected Health Information. I also give my permission for Team Gleason to share the information provided by me to Team Gleason to any organization that Team Gleason will contact to help me with my care or to provide a service. I hereby authorize the release of my information, which may be considered “Protected Health Information” or “PHI”, including medical records related to healthcare or evaluations for DME (Durable Medical Equipment), and all information I have included on the Team Gleason Application for Assistance. Team Gleason may allow business associates who provide services on Team Gleason’s behalf to access my PHI. Our business associates will agree to take appropriate steps and necessary safeguards to properly protect your information. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining assistance from Team Gleason. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. This PHI may be used by Team Gleason for the following:

• to contact DME manufacturers, wheelchair manufacturers, speech generating device manufacturers, any provider of the equipment and technology mentioned above, physicians, clinicians, physical therapists, occupational therapists, speech language pathologists, ALS clinic coordinators, or any other healthcare party on my behalf. Team Gleason may use and/or disclose my PHI to assist me with health care products or services or to coordinate and/or help manage my health care with other providers.
• to make a payment for services or equipment on my behalf. This may include information that identifies me, as well as my diagnosis and the products or services I have requested.
  • administrative, operational, quality assurance, or other activities. For example, Team Gleason may use my PHI to monitor the performance of the equipment and technology specialists who have provided service(s) to me.
    • for law enforcement purposes if asked to do so by a law enforcement official.
    • as part of a fundraising effort.
• when or if necessary to prevent a serious threat to my health and/or safety and/or that of another person.
• to create social media posts, include in printed material, electronic material such as emails, fundraising campaigns, or other uses related to the previously listed items.

COVID-19. Team Gleason makes no representations, warranties, or guarantees about the cleanliness, sterilization, or sanitariness of any equipment. I agree to accept the equipment “as is” and Team Gleason is not required to perform any cleaning or sterilization of the equipment. I understand that there are certain risks, including but not limited to, sickness, injury, disability, or death, resulting from the use and/or possession of the equipment caused by possible infections, viruses, illnesses, or diseases, including but not limited to, COVID-19. I assume full responsibility for any and all risks arising directly or indirectly from the use and/or possession of the equipment. I, my heirs, executors, administrators and representatives, do hereby agree and will indemnify, absolve and hold harmless the Released Parties from any and all claims brought against the Released Parties that may arise out of my conduct in connection with respect to any and all sickness, injury, disability, or death, resulting from the use and/or possession of the equipment caused by possible infections, viruses, illnesses, or diseases, including but not limited to COVID-19. Said indemnity shall include all amounts of damages, interest, costs, penalties, and the like that may be cast upon the Released Parties and any and all attorney’s fees incurred in connection with the defense of any and all claims brought against the Released Parties in connection with the aforementioned conduct.

COVID-19 & Travel. I am fully aware of the current global COVID-19 virus outbreak, the current travel restrictions, and inherent risks involved if choosing to travel and participate in Team Gleason Adventures during this time. I understand that it is my responsibility to check the latest travel information regarding the virus outbreak and understand the inherent and potential health risks of travel during this time. I fully and unconditionally consent, understand, and agree to fully release, indemnify, and hold Team Gleason harmless from any and all travel restrictions, cancellations, financial loss, quarantining rules or measures put in place at airports or destinations I am traveling through illness, or death. I am aware that it is my personal decision to travel and am doing so with full knowledge of current travel recommendations and travel restrictions with regards to the COVID-19 virus and take full responsibility for my actions with regards to this.

Entire Agreement; Amendments. This Agreement contains the entire agreement of the parties with respect to the subject matter of this Agreement, and supersedes all prior negotiations, agreements and understandings with respect thereto. This Agreement may only be amended by a written document duly executed by all parties.