Risk Indemnity Form

RISK WARNING AND EXCLUSION OF LEGAL LIABILITY

This form is designed for Participants who wish to undertake additional activities that may cause risk to them.

It is a Duty of Care of service provider to inform each participant of the risks to them if undertaking any risky activity, and if the participant wishes to partake in this activity, it is at their own risk.

This form must be signed by the participant prior to being accepted as a Participant.

Please carefully read the following acknowledgments and assumptions of risk relating to at-risk activities that you wish to be provided by the provider as outlined below:

Participant Details

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Participant's Name

Email

Participant's Representative

NDIS Number

Date of Birth

Address

Address Line 1

City

State / Province / Region

Checkboxes

I acknowledge that detrimental and risky activities that I choose to undertake might carry some risks and/or dangers which could include physical injury that may result in permanent disability or death, economic loss and/or damage.
I acknowledge that the service provider has advised me that this activity may be detrimental to my health and has informed me of the potential risks.
I agree that the service can prevent me from undertaking this activity if they feel that I may be injured.
I have/will carefully take into consideration the risk/s involved, before participating in activities offered.
I agree that should I choose to participate in the activities offered, it will be entirely at my own risk.
I confirm that I have read and understood and accept the terms and conditions of the above Indemnity associated with the receipt of services.
I agree and consent to an electronic signature.

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Participant / Participant's Representative

Form Completion Date

Care Zone Representative

Participant or Participant's Representative Signature

This form will be saved & placed on the participant's file and retained as per Care Zone's policy and procedures.

If requested, a copy of this form will be made available to the participant and/or the participant’s representative.

RISK WARNING AND EXCLUSION OF LEGAL LIABILITY

Participant Details

USEFUL LINKS