Form DHHS-0003 "Liability Waiver for Employees, Activities Leaders and Class Coordinators, and State Employees' Spouses and Children 18 Years Old or Older Using the Haywood Gymnasium Facility" - North Carolina

What Is Form DHHS-0003?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2014;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHHS-0003 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DHHS-0003 "Liability Waiver for Employees, Activities Leaders and Class Coordinators, and State Employees' Spouses and Children 18 Years Old or Older Using the Haywood Gymnasium Facility" - North Carolina

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NC DHHS LIABILITY WAIVER FOR EMPLOYEES, ACTIVITIES LEADERS
AND CLASS COORDINATORS, AND STATE EMPLOYEES’ SPOUSES AND
CHILDREN 18 YEARS OLD OR OLDER USING THE HAYWOOD GYMNASIUM FACILITY
Acknowledgement and Release of Liability
I request authorization to use the Haywood Gymnasium facility (the “Gym”). I acknowledge that my use of the Gym is
expressly conditioned on my agreement to each of the terms in this document. I acknowledge and agree as follows:
1.
Use of the Gym involves physical exercise, sport, wellness, and recreational activities that may cause injury. I understand that
there is an inherent risk of injury when choosing to participate in any physical exercise, sport, wellness, and/or recreational
activities. My use of the Gym is a voluntary activity in all respects and I assume all risks of injury and illness that may result
from such use. This includes any sponsored group activities or individual use of the Gym and/or exercise equipment.
2.
As the participant, I recognize and acknowledge that there are risks of physical injury and I agree to assume the full risk of any
injuries (including death), damages, or loss which I may sustain as a result of participating in any and all activities arising out
of, connected with, or in any way associated with my use of the Gym. I acknowledge that my participation and use of the Gym
is voluntary.
3.
I hereby fully release and discharge that State of North Carolina, Department of Health and Human Services (NC DHHS) and
their agents, employees and the sponsors, and those whose facilities are being used for this program (collectively, the
“Released Parties”) from any and all liability, claims, and causes of action from injuries or illness (including death), damages,
or loss which I may have or which may accrue to me based on my participation in all activities utilizing the Gym. This is a
complete and irrevocable release and waiver of liability. Specifically, and without limitation, I release the Released Parties
from any liability, claim, or cause of action arising out of the Released Parties’ negligence. I covenant not to sue the Released
Parties for any alleged liabilities, claims, or causes of action released hereunder.
4.
I further agree to indemnify and hold harmless and defend the Released Parties from any and all claims resulting from injuries
or illness (including death), damages, or loss, including, but not limited to attorneys’ fees, sustained by me arising out of,
connected with, or in any way associated with, my use of the Gym.
5.
In the event of any emergency, I authorize the Released Parties to secure from any licensed hospital, physician, and/or
medical personnel any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of
any and all medical services rendered.
6.
I understand that it is my responsibility to consult a physician before I undertake any physical exercise program. I certify that I
am in good health and sufficient physical condition to properly use the Gym; that I am knowledgeable about the proper use of
any equipment that I will use and the rules of any activities that I will participate in; and that I will carefully read the operating
instructions available to me for any Gym equipment prior to use and will operate such equipment in strict accordance with
instructions.
7.
The Released Parties are not responsible for any loss or theft of personal property brought to or left in the Gym and I release
the NC DHHS from any liability for such loss or theft.
8.
I attest that I am a current or retired State government employee, or that I am employed as a temporary employee through
Temporary Solutions. I understand that if I separate from State government employment or separate from Temporary
Solutions, other than through retirement, I will no longer be eligible to use the Gym.
9.
I understand and agree to adhere to the NC DHHS Gym’s policies and rules, which are available for review online in the
department’s Policy and Procedure Manual, XI-Employee Wellness, Use of Haywood Gymnasium policy
(http://info.dhhs.state.nc.us/olm/manuals/dhs/pol-92/man/HaywoodGym1.htm), and/or the DHHS Employee Wellness website
for this same policy. I further agree to adhere to the following rules regulating use of the Gym:
a.
Only current NC DHHS employees (including Temporary Solutions’ employees working at a DHHS Division/Facility and
retired DHHS employees) are eligible to use the Gym during ‘Free Time’ when the Gym is not being utilized by a DHHS
approved Program.
i. ‘Free Time’- time during which employees can utilize the Gym’s indoor perimeter, court, and Exercise Room.
b.
NC DHHS and other State employees (including retired State employees, Temporary Solutions employees, and current
State employees’ spouses and children 18 years old and older) are eligible to participate in the following DHHS
approved Programs held in the Gym: exercise classes, volleyball league, and pick-up basketball league.
c.
State employees employed in other State agencies, and their spouses and children 18 years old and older, are eligible
to participate in exercise classes, volleyball league, and pick-up basketball league, but are not eligible for ‘Free Time’
access to the Gym.
NC DHHS LIABILITY WAIVER FOR EMPLOYEES, ACTIVITIES LEADERS
AND CLASS COORDINATORS, AND STATE EMPLOYEES’ SPOUSES AND
CHILDREN 18 YEARS OLD OR OLDER USING THE HAYWOOD GYMNASIUM FACILITY
Acknowledgement and Release of Liability
I request authorization to use the Haywood Gymnasium facility (the “Gym”). I acknowledge that my use of the Gym is
expressly conditioned on my agreement to each of the terms in this document. I acknowledge and agree as follows:
1.
Use of the Gym involves physical exercise, sport, wellness, and recreational activities that may cause injury. I understand that
there is an inherent risk of injury when choosing to participate in any physical exercise, sport, wellness, and/or recreational
activities. My use of the Gym is a voluntary activity in all respects and I assume all risks of injury and illness that may result
from such use. This includes any sponsored group activities or individual use of the Gym and/or exercise equipment.
2.
As the participant, I recognize and acknowledge that there are risks of physical injury and I agree to assume the full risk of any
injuries (including death), damages, or loss which I may sustain as a result of participating in any and all activities arising out
of, connected with, or in any way associated with my use of the Gym. I acknowledge that my participation and use of the Gym
is voluntary.
3.
I hereby fully release and discharge that State of North Carolina, Department of Health and Human Services (NC DHHS) and
their agents, employees and the sponsors, and those whose facilities are being used for this program (collectively, the
“Released Parties”) from any and all liability, claims, and causes of action from injuries or illness (including death), damages,
or loss which I may have or which may accrue to me based on my participation in all activities utilizing the Gym. This is a
complete and irrevocable release and waiver of liability. Specifically, and without limitation, I release the Released Parties
from any liability, claim, or cause of action arising out of the Released Parties’ negligence. I covenant not to sue the Released
Parties for any alleged liabilities, claims, or causes of action released hereunder.
4.
I further agree to indemnify and hold harmless and defend the Released Parties from any and all claims resulting from injuries
or illness (including death), damages, or loss, including, but not limited to attorneys’ fees, sustained by me arising out of,
connected with, or in any way associated with, my use of the Gym.
5.
In the event of any emergency, I authorize the Released Parties to secure from any licensed hospital, physician, and/or
medical personnel any treatment deemed necessary for my immediate care and agree that I will be responsible for payment of
any and all medical services rendered.
6.
I understand that it is my responsibility to consult a physician before I undertake any physical exercise program. I certify that I
am in good health and sufficient physical condition to properly use the Gym; that I am knowledgeable about the proper use of
any equipment that I will use and the rules of any activities that I will participate in; and that I will carefully read the operating
instructions available to me for any Gym equipment prior to use and will operate such equipment in strict accordance with
instructions.
7.
The Released Parties are not responsible for any loss or theft of personal property brought to or left in the Gym and I release
the NC DHHS from any liability for such loss or theft.
8.
I attest that I am a current or retired State government employee, or that I am employed as a temporary employee through
Temporary Solutions. I understand that if I separate from State government employment or separate from Temporary
Solutions, other than through retirement, I will no longer be eligible to use the Gym.
9.
I understand and agree to adhere to the NC DHHS Gym’s policies and rules, which are available for review online in the
department’s Policy and Procedure Manual, XI-Employee Wellness, Use of Haywood Gymnasium policy
(http://info.dhhs.state.nc.us/olm/manuals/dhs/pol-92/man/HaywoodGym1.htm), and/or the DHHS Employee Wellness website
for this same policy. I further agree to adhere to the following rules regulating use of the Gym:
a.
Only current NC DHHS employees (including Temporary Solutions’ employees working at a DHHS Division/Facility and
retired DHHS employees) are eligible to use the Gym during ‘Free Time’ when the Gym is not being utilized by a DHHS
approved Program.
i. ‘Free Time’- time during which employees can utilize the Gym’s indoor perimeter, court, and Exercise Room.
b.
NC DHHS and other State employees (including retired State employees, Temporary Solutions employees, and current
State employees’ spouses and children 18 years old and older) are eligible to participate in the following DHHS
approved Programs held in the Gym: exercise classes, volleyball league, and pick-up basketball league.
c.
State employees employed in other State agencies, and their spouses and children 18 years old and older, are eligible
to participate in exercise classes, volleyball league, and pick-up basketball league, but are not eligible for ‘Free Time’
access to the Gym.
d.
Non-State employees are not eligible to utilize the Gym, and are eligible for ‘observer’ access in the Gym only and must
be accompanied by a State employee at all times. There are no exceptions or grandfathering of non-State employees
into participating in any Gym activities.
e.
Non-State employees are not eligible to participate in the DHHS approved exercise classes, volleyball league, and pick-
up basketball league, and are not eligible for ‘Free time’ access to the Gym.
f.
Gym usage as indicated above is limited to persons age 18 years old and older; persons under age 18 are eligible for
‘observer’ access only and must be accompanied by a State employee at all times.
g.
Employees have access to the Gym for wellness activities solely on a voluntary basis on their own time and should
seek medical approval before starting any new exercise program.
h.
Employees are allowed unscheduled individual access to the Exercise Room during operating hours of the Gym, 6:00
a.m. to 9:30 p.m., Monday through Friday.
i.
When DHHS approved Programs or events are not scheduled, DHHS employees also can have unscheduled or ‘Free
Time’ access to the main gym for walking and court use. Employees should check the NC DHHS Wellness website
regarding DHHS approved Programs and department events scheduled in the Gym.
j.
Approved DHHS Programs shall be given the following priority in regards to Gym usage:
1)
Scheduled department and Dix-campus divisions’ meetings, events, blood drives, flu shot clinics, and public
forums;
2)
Scheduled group wellness-related activities such as exercise classes and team sports leagues;
3)
Unscheduled DHHS employee access to the Exercise Room and/or to the court when not in use for scheduled
Programs and activities; and
4)
Other state agencies and non-profit groups.
k.
Access for individual wellness activities is limited to NC DHHS employees with a DHHS issued badge or key card
access for the Gym. The badge or key card will allow the employee unscheduled access to the Exercise Room, 6:00
a.m. to 9:30 p.m., Monday through Friday. Entrance is through the main gym door on Pedneau Drive.
l.
Only current DHHS employees (including Temporary Solutions employees working at a DHHS Division/Facility and
retired DHHS employees) are eligible for a badge or key card to access the Gym during ‘Free Time’ when the Gym is
not being utilized by a DHHS approved Program.
m.
DHHS and other State employees who serve as an Activities Leader for an exercise class, volleyball league, or pick-up
basketball league are eligible for a badge or key card to access the Gym during their Program.
n.
Non-State employees who serve as an Activities Leader for an exercise class are eligible for a badge or key card to
access the Gym during their Program.
o.
DHHS and other State employees taking exercise classes, participating in the volleyball league, and/or playing in a
pick-up basketball league are not provided a badge or key card to access the Gym, and would enter the gym through
their Activities Leader.
p.
Before receiving a badge or key card access to the Gym, employees must submit this signed Haywood Gymnasium
Facility Liability Waiver form, as well a signed Fitness through Work Liability Waiver form, to their Division/Facility
Wellness Leader/Representative who will request a DHHS badge or key card access for the employees.
q.
Employees using the Gym should use the Visitor parking spaces in front of and behind the Gym, and other Visitor
parking spaces available on the Dix Campus.
r.
When there is a charge for any wellness activity, payment is the sole responsibility of the employee.
s.
Access to the Exercise Room equipment is on a first come, first serve basis. The amount of equipment is limited and
employees are asked to limit their use on the exercise equipment when others are waiting to use it.
t.
Employees and Activities Leaders are responsible for leaving the Gym clean, ensuring all of the doors to the Gym are
properly locked before exiting the facility, and following these rules regulating use of the Gym.
u.
Any Gym maintenance issues and/or problems with exercise equipment should be reported to the NC DHHS Wellness
Coordinator.
v.
Employees must supply their own towels and soap should they choose to use the Gym shower facilities.
w.
Gym lockers can be used only while the employee is at the Gym. Employees must provide their own locks. Any items
left in the lockers will be removed as will locks.
x.
For safety and security, employees are encouraged not to use the Gym alone. This is especially important in the
evening and early morning hours.
y.
In case of emergency, employees should call 911 and/or the State Capitol Police at 919-733-4646.
z.
All areas of the Gym shall remain alcohol, drug, and tobacco free at all times.
aa.
Failure to observe the rules listed above can result in termination of an employee’s access to the Gym, and/or
disciplinary action, up to and including dismissal.
bb.
Gym entrances and interior are under 24-hour recorded video surveillance.
I have read and fully understand this Acknowledgement and Release of Liability set forth above, including the permission
to secure medical treatment and the release of all claims, including claims for the negligence of the Release Parties. I am
18 years old or older. I understand that my signed waiver will be retained in my employee personnel file and/or my
Activities Leader’s file. This document is binding upon me and my heirs, children, wards, personal representatives and
anyone entitled to act on my behalf.
Signed: _________________________________________
Printed Name:
___________________________________________
Department/Division/Facility: ______________________________________________________________
Date: ____________
DHHS-0003, 4/14
Revised 04/2014
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