MULTI-COUNTY COUNSELING, INC.
FULL AND COMPLETE RELEASE OF TRANSPORTATION LIABILITY AND INDEMNITY AGREEMENT
I,_________________________________________(Circle One): Client, Parent of Client, Guardian of Client, and/or Legal Custodian of Client
Name of Identified Client and/or Authority
(hereinafter referred to as SIGNER) of NAME: _________________________________________ SSN: ______________________
Identified Client
Identified Client
DOB: _____/_____/_____ , being at least 18 years of age, hereby represents that, in exchange for Multi-County Counseling, Inc.
Identified Client
(hereinafter referred to as MCCI) making transportation to and/or from Outpatient Treatment Services/Activities (hereinafter referred to as
OUTPATIENT) available to Identified Client, hereby contract and agree as follows:
THE SIGNER, agrees and understands that being transported in a motor vehicle can be a HAZARDOUS ACTIVITY which may result in INJURY or
DEATH to the Identified Client DURING TRANSPORTATION for participation in OUTPATIENT. Hazards exist which have the potential for resulting
in an automobile collision including, but not limited to: Road conditions which vary constantly because of weather changes; The presence of other
drivers; and/or, Other natural or manmade obstacles. Even transportation in the best automobile cannot guarantee personal injury and/or death
prevention. PARTICIPATION IN OUTPATIENT SHALL NOT IN ANY WAY ELIMINATE THE INHERENT RISKS IN AUTOMOBILE
TRANSPORTATION.
THE SIGNER, represents to MCCI that they have the authority to enter into this contract on behalf of themselves and/or said Identified Client and/or
on behalf of any parent or guardian of said Identified Client and AGREES TO DEFEND AND INDEMNIFY AND HOLD HARMLESS MCCI from any
and all claims arising from the Identified Client’s transportation to and/or from OUTPATIENT; and, This contract brought on behalf of the Identified
Client and/or any parent/guardian of the Identified Client thereof, even after the Identified Client has attained majority, or from third parties injured by
the Identified Client or by any parent/guardian of the Identified Client, and hold MCCI, its representatives, agents, affiliates, officers, directors,
servants and employees HARMLESS from any such claim, legal action, harm, injury, damages or loss to person and/or property, including but not
limited to attorney’s fees and costs.
THE SIGNER hereby ASSUMES ALL RISKS for the Identified Client in connection with the Identified Client’s transportation to and/or from
OUTPATIENT including, but not limited to, personal injury and death, and HEREBY COMPLETELY RELEASES MCCI, its representatives, agents,
affiliates, officers, directors, servants and employees from ALL LIABILITY for any injuries, death or damages and from any claim or legal action by
the Signer, any parent or guardian of the Identified Client, the Identified Client, anyone on behalf of the Identified Client; and/or, by the Signer’s or
Identified Client’s estate, heirs and assigns arising in any way from the Identified Client’s transportation to and/or from OUTPATIENT, including any
claim based on NEGLIGENCE.
THE SIGNER further AUTHORIZES anyone working at MCCI to call for such medical care for the Identified Client or to transport the Identified Client
to the appropriate clinic or hospital if, in the opinion of anyone working at MCCI, medical attention is needed for the Identified Client.
THE SIGNER agrees that upon turning the Identified Client over to the Signer, or their Designees, or to any Ambulance, Other Medical Transport,
Medical Facility, Clinic or Hospital that the responsibility of MCCI shall be totally fulfilled and MCCI shall not have any further responsibility for the
Identified Client. THE SIGNER AGREES TO PAY ALL COSTS associated with such medical care and related transportation for the Identified Client
and INDEMNIFY and HOLD MCCI, its representatives, agents, affiliates, directors, servants and employees HARMLESS from any costs incurred
therein, or any claims arising therefrom.
In exchange for, and in consideration of, MCCI making transportation to and/or from OUTPATIENT available to the Identified Client, THE SIGNER,
CONTRACTUALLY AGREES that any and all disputes between the Signer and/or the Identified Client and/or any parent/guardian of the Identified
Client, and/or anyone on behalf of the Identified Client and MCCI arising from the Identified Client’s transportation to and/or from OUTPATIENT for
participation in OUTPATIENT, and including any claims for personal injury and/or death, will be GOVERNED BY THE LAWS OF THE STATE OF
OKLAHOMA and the EXCLUSIVE JURISDICTION thereof will be in the state or federal courts of the STATE OF OKLAHOMA.
I, THE SIGNER, have carefully read the foregoing FULL AND COMPLETE RELEASE OF LIABILITY AND INDEMNITY AGREEMENT and
understand its contents, including the jurisdictional agreement. I, THE SIGNER, ACKNOWLEDGE AND UNDERSTAND this is a FULL AND
COMPLETE RELEASE OF LIABILITY AND INDEMNITY AGREEMENT, that it includes any and all claims by the Signer, the Identified Client, or
anyone else on behalf of the Signer and/or Identified Client for any reason, INCLUDING NEGLIGENCE and that I, THE SIGNER, am contractually
agreeing to these terms FREELY, FULLY AND WITHOUT RESERVATION in exchange for the right to receive transportation to and/or from
OUTPATIENT for participation in OUTPATIENT at MCCI.
If any part of this agreement is deemed unenforceable, the remainder shall be an enforceable contract between the parties.
I AM AWARE THAT THIS CONTRACT IS LEGALLY BINDING AND THAT I, THE SIGNER, AM RELEASING LEGAL RIGHTS BY SIGNING IT.
Please print name of: Client, Parent, Guardian or Legal Custodian__________________________________
Signature of: Client, Parent, Guardian or Legal Custodian ________________________________________(Signer) Date_____________
Address_______________________________ City_______________ State______Zip_______________
Phone (______)__________________ E-mail Address_________________________________________