Woodinville Fire and Life Safety District Woodinville, Washington

Community Emergency Response Team Program

Hold Harmless/Permission Request

I, _________________________________________, hereby request permission to participate in the Woodinville Fire and Life Safety District Community Emergency Response Team (WFLSDCERT) Program. I understand that this training will involve active physical participation, which includes a potential risk of personal injury and/or personal property damage. I make this request with full knowledge of the possibility of personal injury and/or personal property damage. Further, I have read and understand the program outline that describes all class sections and the associated activities.

I agree to hold the American Red Cross, the American Heart Association, WFLSDCERT, the Woodinville Fire and Life Safety District, the City of Woodinville, and their agents and personnel, harmless from any and all claims, actions, suits, and/or injury that I may suffer and which may arise as a result of my participation in the above mentioned class.

I agree to follow the rules established by the instructors, and to exercise reasonable care while participating in the WFLSDCERT program. I understand that if I fail to follow the instructor’s rules and regulations or if I fail to exercise reasonable care, I can be administratively removed from the program.

By executing this release I certify that I have read this release in its entirety, understand all of its terms and have had any questions regarding the release or its effect satisfactorily answered. I sign this release freely and voluntarily.

Signature

Date

Emergency Contact Name

Emergency Contact Phone Number

Comments:

Signature of Instructor

Date