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RELEASE AND HOLD HARMLESS AGREEMENT

There are risks and dangers inherent when participating in emergency care training classes. These risks include, but are not limited to, injuries during skills practices; back injuries from moving a simulated victim; acquiring communicable diseases; or performing skills on fellow students.

Neither Health and Safety Institute (“HSI”) nor Defensive Skills Academy, LLC ("Training Center") can guarantee the safety of participants, but Training Center's authorized and affiliated instructors are trained to take reasonable precautions to minimize risks and safeguard participants health and safety during training, including:

  • Providing each class participant with sanitary personal protective equipment, including, but not limited to, breathing barriers (face shields/masks) and gloves; and

  • Providing training manikins to practice skills such as chest compressions, abdominal thrusts, and rescue breathing that are not appropriate for student-on-student practice.

In addition, instructors and participants should avoid awkward or extreme body positions to avoid back or other injuries from improper lifting and moving. Instructors and participants should not practice moving simulated victims if they have a history of back problems because such practice may aggravate previous back injuries. Please advise instructor prior to the beginning of class of any illnesses or current injuries. Once participating in the class training, it will be assumed you are physically able to do so if the instructor was not advised.

Knowing this, I assume the risks inherent in this class and:

  • I hereby voluntarily release and hold HSI and Training Center, and each of their officers, agents, employees and volunteers, harmless from any and all liability or costs from injury associated with or arising from my participation in this class, including from negligence.

  • I understand and agree that this Release applies to personal injury, including death, and property damage which I may suffer.
  • I understand and agree that this Release will be binding on my, my spouse, my heirs, my personal representatives, my assigns, my children, and any guardian appointed by the court for said children.
  • I have read this Release, and I understand it.

Some states may not allow a release of liability, so this Release or parts of it may not apply to you.


First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
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Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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