MI-SNAP Resident (or Child/Dependent) Registration Form
Michigan Special Needs Awareness Program Registration for Downriver community members with special needs/disabilities (or their child/dependent with special needs/disabilities)
PARTICIPANT WAIVER AND RELEASE OF LIABILITY In consideration of the opportunity to participate in the Mimi’s Mimi’s Mission 911 Registration Program (Program), whose registration process requires me to accept this agreement, I hereby agree to the following Waiver and Release of Liability (Agreement): 1. Waiver and Release of Liability: My participation in the Program is voluntary and subjects me to the possibility of delay and/or errors in the entry of my registration information and exposure to injury or death during an emergency response (collectively, Risks). Accordingly, I agree to the following: a. I hereby release and hold harmless Mimi’s Mission, its officers, directors, employees, agents, volunteers, and contractors (collectively, Releasees) from any claim, demand, loss, liability, damages, and attorney fees and costs whatsoever arising from, related to, or resulting from these Risks (Claims), including those caused by the negligent acts or omissions of any or all of the Releasees. b. I recognize there are Risks involved in my participation in the Program and attest and certify that I recognize that the potential benefits to me and my family of registering with the Program outweigh those Risks. c. This Agreement shall be binding on my estate, heirs, executors, administrators, successors, and assigns, as well as any other party asserting a Claim on my behalf or on behalf of my estate. 2. General Provisions: a. I hereby expressly agree that (1) this Agreement shall be governed and construed according to the laws of the state of Michigan without regard to its conflict of law provisions and (2) any action or proceeding concerning any Claim or the meaning or effect of any provision of the Agreement shall be conducted only in the federal or state courts located in Wayne County, Michigan, and that for such purposes, I expressly submit to the jurisdiction of such courts. b. This Agreement contains the entire understanding between and among the parties concerning these matters. No waiver, modification, or amendment of any of the terms of this Agreement shall be effective unless made in writing and signed by the party to be charged. c. I hereby expressly agree that if any portion of this Agreement is held invalid, the balance of the Agreement shall nonetheless continue in full legal force and effect. *
Today's Date *
Are you filing out this form for yourself or someone else? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service