Westland Fire Durable Medical Supply Loan Closet

All requests for durable medical supplies from the Westland Fire Department must be submitted via online via this form.

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Full Name (*)
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Address
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City
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State:
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Zip Code
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Date of Birth MM/DD/YYY (*)
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Drivers License Number (*)
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Phone Number
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Aternate Phone Number
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E-mail (*)
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Best method to contact you (*)
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Select the supply you need (*)




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RELEASE OF LIABILITY AGREEMENT

By signing this document you will waive certain legal rights including the right to sue. Please read carefully:

In consideration of being allowed to participate in any way in the City of Westland medical equipment loan program, I, the person named on this form, acknowledge, appreciate, and agree that:

1. The risk of injury from the activities involved with using equipment in this program is significant, including the potential for permanent paralysis and death, and while particular skills, and other equipment, and personal discipline in using said medical devices may reduce this risk, the risk of serious injury does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation and use of this equipment; and,

3. I willingly agree to comply with the reasonable, safe and intended use of this equipment. If, however, I observe any unusual significant hazard such as broken pieces or faulty construction of the loaned equipment during its use, I will discontinue its use immediately, then return the broken piece to the loan program; and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE CITY OF WESTLAND, its officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my use of the equipment, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I fully understand and agree that this equipment and its use holds inherent risks, dangers and hazards, and that my use of such equipment may result in injury or illness including, but not limited to, bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability. These risks and dangers may be caused by the negligence of the owners, employees, officers or agents of THE CITY OF WESTLAND, the negligence of others, accidents, breaches of contract, the unpredictable forces and/or elements of nature or other causes. Risks and dangers may arise from foreseeable or unforeseeable causes.

I confirm that I am physically capable and fit to use this equipment.I confirm that I am eighteen (18) years of age or older. (Minors must have a parent or guardian read and sign in their stead.)

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Liability Acceptance (*)
You must agree to all the terms of the Release of Liability Agreement to submit this form.
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