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<br />ATTACHMENT A <br /> <br />~.-"... <br />~ <br /> <br />COUNTY OF ORANGE HEALTH CARE AGENCY <br />BICYCI,E HELMET PROGRAM <br />VOLUNTARY RELEASE - ASSUMPTION OF RISK AND INDEMNITY AGREEMENT <br /> <br />Each undersigned person requests and is granted permission to attend a one-on-one bicycle <br />helmet fitting by a trained hi cycle helmet fitter and will receive a new bicycle helmet at no cost. In <br />consideration of the receipt of a bicycle hclmet and bicycle helmet fitting, I <br />for mysclf, my personal representatives, heirs, next of <br /> <br />(eal:h of the: undersigned) <br />kin, spouse, and assigns, DO HEREBY: <br /> <br />L RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the County of Orange, its elected and <br />appointed officials, officers, employees. agents and those special districts and agencies fur which <br />County's Board of Supervisors acts as the governing Board (County Indemnitees) and distributing <br />agency from any and all claims and liability arising out of strict liability or ordinary negligence which <br />causes any harm, injuryl or damage which may be sustained, incurred, or suffered whether foreseen or <br />unforeseen, arising from or connected in any way to my child's participation in the Bicycle Helmet <br />Program, including injury as a result of use of the bicycle helmet and bicycle helmet fitting. <br /> <br />2. COVENENT to hold County Indemnitecs and distributing agency harmless and indemnify them from <br />any claim, loss, demand, judgment or expense they may incur arising out of my child's participation in <br />the Bicyclc Helmet Pro,,'Tam and use of thc bicycle helmet provided. <br /> <br />3. UNDERSTAND that to have protective bcncfit of a bicycle helmet, the bicycle hclmet must be <br />pt:riodically checked to maintain proper fit, as explained in the information card, Helmet Fitting Tips, <br />provided by the distributing agency, that my child should immediately stop using the bicycle hclmet if it <br />is in a crash or damaged in any way, and that the use of this bicycle helmet cannot guarantee that my <br />child will not be injured while riding a blcycle. <br /> <br />4. ACKNOWLEDGE that no oral representations or inducements have been made to me to sign this <br />Agreement. If any portion of this agreement is held invalid, it is agreed that the balance thereof shall <br />continue in fun legal force and effect. <br /> <br />I HAVE READ THIS DOCUMENT. I UNDERSTAND IT IS A RELEASE OF ALL CLAIMS. <br />I VOLUNTARILY SIGN MY NAME EVIDENCING MY ACCEPTANCE OF THE ABOVE <br />PROVISIONS. <br /> <br />Parent/Guardian Signature <br /> <br />Date <br /> <br />White (Parent/Guardian) <br /> <br />Yellow (OCHCA) <br /> <br />Pink (Grantee) <br /> <br />I of! <br />X:\CONTRACT 2006_07\Bc1eHlmlSfty-Santa Ana City-06-Q7 -HH,doc <br /> <br />ATIACHMENT A <br />KK07 <br />