PUBLIC HEALTH and SOCIAL SERVICES DEPARTMENT     Schelli Slaughter - Director
COUNTY  COMMISSIONERS                                                                                                                                                                                  Dr. Dimyana Abdelmalek - Health Officer 
Carolina Mejia District One                                                                                                                                                                                                                    
Gary Edwards  District Two
Tye Menser     District Three

ANNUAL LIABILITY RELEASE FORM

The release below must be signed by the person authorized for signing legal documents. 

I acknowledge that I have familiarized myself with the description of the activities listed in the quarterly program brochure.  Programs include, but are not limited to, day trips, monthly activities, and weekly fitness programs.  Further, I understand the hazards and my personal limitations and knowingly assume all risks.  In consideration for the activities provided by Thurston County Public Health and Social Services Department, I personally, or on behalf of my child, assume all risks and hazards incidental to the programs listed in the quarterly program brochure. I hereby release Thurston County Public Health and Social Services Department from any and all claims. In the event that an applicant fails to sign this registration form, but an applicant pays the necessary fees to participate in the program, then the applicant shall assume all risks and hazards incidental to the program and agree to release the Thurston County Recreation Services Department and its employees and agents from any and all claims. Further, I authorize Public Health and Social Services to speak with my or my child’s Case Resource Manager. 

If DDA Respite/IFS  Funds are used to pay for participating in programs,  please read: Additionally, I release the State of Washington and all of its agencies, agents, contractor, servants, and employees from liability for any acts of the contractor causing injuries arising out of premises operation, acts of independent contractors, products completion, or personal injuries sustained due to contractor’s negligence in connection with providing services under this contract.

Please choose one: *
If not the above named participant, have you reviewed this release with the participant named above? *
Signature: *
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412 Lilly Rd. N.E., Olympia, Washington 98506-5132
(360) 867-2588  FAX (360) 867-2600  TDD (360) 867-2603 TDD (800) 658-6384
https://www.co.thurston.wa.us/health