"Waiver and Release From Liability - Infants in the Workplace" - Vermont

Waiver and Release From Liability - Infants in the Workplace is a legal document that was released by the Vermont Department of Human Resources - a government authority operating within Vermont.

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WAIVER AND RELEASE FROM LIABILITY
– Infants in the Workplace
Related Policy: Infants in the Workplace, No. 13.13
About this form: Because of the risks inherent in the workplace, Parents and their designated care
providers are required to provide this Waiver and Release from Liability in order to participate in the State
of Vermont’s Infants in the Workplace Program. This agreement excuses the State of Vermont and the
owner of any leased building in which the State of Vermont operates the Infants in the Workplace program
from liability. PLEASE READ CAREFULLY BEFORE SIGNING.
Parent – complete, sign and provide the completed, signed form to your supervisor, along with
your Parent Agreement.
Care Provider – Complete, sign and provide the completed, signed form to your supervisor along
with your Care Provider Agreement.
PARENT:
I, ________________________ (Parent) desire to participate in the State of Vermont Infants in the
Workplace Program (the "Program").
In consideration for the opportunity to participate in the Program, I expressly, willingly and voluntarily,
for myself and for my child, assume all risks of any and every kind involved with or arising from my and
my child's participation in the Program. I hereby release, waive, discharge and covenant not to sue the
State of Vermont, including all of its agencies, departments, officers, agents and employees from any and
all liabilities, claims, demands, for injury, accidents or illness (including death) that may be sustained by
me or my child while participating in the Program while on premises owned or leased by the State of
Vermont.
I further agree to assume full responsibility for any risks of injury, accident or illness (including death)
which may be sustained by me or my child as a result of participating in the Program. I hereby
acknowledge that my participation in the Program is voluntary and that I knowingly assume all such
risks. In addition, I agree to indemnify and hold harmless the State of Vermont, including all of its
agencies, departments, officers, agents and employees for any loss, liability, damage or cost, including
courts costs and attorneys’ fees that may occur as a result of my participation in the Program.
THIS WAIVER AND RELEASE FROM LIABILITY EXTENDS TO AND INCLUDES THE OWNER/LESSOR OF ANY
PREMISES LEASED TO THE STATE OF VERMONT IN WHICH THE PROGRAM OPERATES, INCLUDING FOR
INJURIES, DAMAGE OR LOSSES CAUSED BY THE OWNER/LESSOR'S NEGLIGENCE.
PARENT
ACKNOWLEDGES THAT THE OWNER/LESSOR HAS DISCLAIMED ALL LIABILITY FOR DAMAGE OR INJURY
OCCURRING ON THE PREMISES TO PARTICIPANTS IN THE PROGRAM.
THIS WAIVER AND RELEASE IS BINDING ON ME, MY CHILD, MY SPOUSE AND ANY OTHER PERSON WITH
LEGAL RIGHTS AND RESPONSIBILITIES FOR MY CHILD.
WAIVER AND RELEASE FROM LIABILITY
– Infants in the Workplace
Related Policy: Infants in the Workplace, No. 13.13
About this form: Because of the risks inherent in the workplace, Parents and their designated care
providers are required to provide this Waiver and Release from Liability in order to participate in the State
of Vermont’s Infants in the Workplace Program. This agreement excuses the State of Vermont and the
owner of any leased building in which the State of Vermont operates the Infants in the Workplace program
from liability. PLEASE READ CAREFULLY BEFORE SIGNING.
Parent – complete, sign and provide the completed, signed form to your supervisor, along with
your Parent Agreement.
Care Provider – Complete, sign and provide the completed, signed form to your supervisor along
with your Care Provider Agreement.
PARENT:
I, ________________________ (Parent) desire to participate in the State of Vermont Infants in the
Workplace Program (the "Program").
In consideration for the opportunity to participate in the Program, I expressly, willingly and voluntarily,
for myself and for my child, assume all risks of any and every kind involved with or arising from my and
my child's participation in the Program. I hereby release, waive, discharge and covenant not to sue the
State of Vermont, including all of its agencies, departments, officers, agents and employees from any and
all liabilities, claims, demands, for injury, accidents or illness (including death) that may be sustained by
me or my child while participating in the Program while on premises owned or leased by the State of
Vermont.
I further agree to assume full responsibility for any risks of injury, accident or illness (including death)
which may be sustained by me or my child as a result of participating in the Program. I hereby
acknowledge that my participation in the Program is voluntary and that I knowingly assume all such
risks. In addition, I agree to indemnify and hold harmless the State of Vermont, including all of its
agencies, departments, officers, agents and employees for any loss, liability, damage or cost, including
courts costs and attorneys’ fees that may occur as a result of my participation in the Program.
THIS WAIVER AND RELEASE FROM LIABILITY EXTENDS TO AND INCLUDES THE OWNER/LESSOR OF ANY
PREMISES LEASED TO THE STATE OF VERMONT IN WHICH THE PROGRAM OPERATES, INCLUDING FOR
INJURIES, DAMAGE OR LOSSES CAUSED BY THE OWNER/LESSOR'S NEGLIGENCE.
PARENT
ACKNOWLEDGES THAT THE OWNER/LESSOR HAS DISCLAIMED ALL LIABILITY FOR DAMAGE OR INJURY
OCCURRING ON THE PREMISES TO PARTICIPANTS IN THE PROGRAM.
THIS WAIVER AND RELEASE IS BINDING ON ME, MY CHILD, MY SPOUSE AND ANY OTHER PERSON WITH
LEGAL RIGHTS AND RESPONSIBILITIES FOR MY CHILD.
Waiver and Release
Page 2
CARE PROVIDER:
I, ________________________ (Care Provider) desire to participate in the State of Vermont Infants in the
Workplace Program (the "Program").
In consideration for the opportunity to participate in the Program, I expressly, willingly and voluntarily
assume all risks of any and every kind involved with or arising from my participation in the Program. I
hereby release, waive, discharge and covenant not to sue the State of Vermont, including all of its
agencies, departments, officers, agents and employees from any and all liabilities, claims, demands, for
injury, accidents or illness (including death) that may be sustained by me while participating in the
Program while on premises owned or leased by the State of Vermont.
I further agree to assume full responsibility for any risks of injury, accident or illness (including death)
which may be sustained by me as a result of participating in the Program. I hereby acknowledge that my
participation in the Program is voluntary and that I knowingly assume all such risks. In addition, I agree
to indemnify and hold harmless the State of Vermont, including all of its agencies, departments, officers,
agents and employees for any loss, liability, damage or cost, including courts costs and attorneys’ fees
that may occur as a result of my participation in the Program.
THIS WAIVER AND RELEASE FROM LIABILITY EXTENDS TO AND INCLUDES THE OWNER/LESSOR OF ANY
PREMISES LEASED TO THE STATE OF VERMONT IN WHICH THE PROGRAM OPERATES, INCLUDING FOR
INJURIES, DAMAGE OR LOSSES CAUSED BY THE OWNER/LESSOR'S NEGLIGENCE. CARE PROVIDER
ACKNOWLEDGES THAT THE OWNER/LESSOR HAS DISCLAIMED ALL LIABILITY FOR DAMAGE OR INJURY
OCCURRING ON THE PREMISES TO PARTICIPANTS IN THE PROGRAM.
The undersigned further expressly agree that the forgoing Waiver and Release from Liability is intended
to be as broad and inclusive as is permitted by the law of the State of Vermont and that if any portion
hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and
effect.
I have read this Waiver and Release from Liability and fully understand its terms. I acknowledge that I am
signing this agreement freely and voluntarily.
Parent Name: _______________________________
Child's Name: _______________________________
Parent Signature: _____________________________
Date: ______________
Care Provider Name: _______________________________
Care Provider Signature: _____________________________
Date: ______________
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