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  • In exchange for participation in the educational training of peripheral intravenous lines (the “Activity”), organized by Intravenous Queen, you hereby agree as follows:

    I - You are an adult, over the age of 18 years old and is cognitively capable to provide consent.

    II - You and anyone claiming on your behalf release and forever discharge Releasee and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them (collectively, the “Released Parties”), in their individual and/or corporate capacities from causes of action of any nature and kind, known or unknown, which you may have against Release or any Released Parties arising out of or relating to any injury, loss or damage to person and property that may be sustained as a result of participation in the Activity (“Claims”).

    III - You understand that participation in the Activity involves inherent risks, including risk of physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent paralysis and/or death, and you assume all related risks and voluntarily participate in the Activity. This includes the possibility of a needlestick injury, infection, disease, and unforeseen injuries.

    a . To minimize the risk of needlestick injury and to promote safety, information and education on needle safety was provided to you prior to the workshop and during the workshop.

    i - You had the opportunity to ask any questions for any clarification on what to do if you sustained a needlestick injury.

    ii - If you have questions about appropriate medical treatment for occupational exposures, assistance is available from the Clinicians’ Post Exposure Prophylaxis (PEP) Line at 1-888-448-4911 or go to: http://www.nccc.ucsf.edu/External. If you experienced a needlestick or sharps injury or were exposed to the blood or other body fluid of a patient during the course of your work, immediately follow these steps:

    1 - Wash needlesticks and cuts with soap and water,
    2 - Flush splashes to the nose, mouth, or skin with water,
    3 - Irrigate eyes with clean water, saline, or sterile irrigants (as needed),
    4 - Report the incident to your supervisor, and
    5 - Immediately seek medical treatment.

    b - You understand that conditions may arise which are unforeseen at this time and that it may be necessary and advisable to provide other variations of care. Examples of these types of situations include but are not limited to: vasovagal syncope causing head injury or other injury, anxiety, fear, palpitations, nausea, vomiting, etc. In cases such as these, you understand that the PIV procedure will be stopped immediately.

    c - If at any time during your participation you sustained a serious injury, you understand that an ambulance may be notified if you become injured. Additionally, you understand that you may be transported to a local emergency department for an evaluation of the injuries sustained during your volunteering at the workshop. You understand that you will take full financial responsibility for any urgent care/hospital/emergency department cost.

    IV - You agree to indemnify Releasee against any and all claims, actions, lawsuits, damages and judgments, including attorney’s fees, arising out of or relating to my participation in the Activity.

    V - This Release for Participation in Event or Activity (“Release”) shall not be in any way construed as an admission by the Releasee that it has acted wrongfully with respect to me or any other person, that it admits liability or responsibility at any time for any purpose, or that I have any rights whatsoever against the Releasee.

    VI - This Release shall be binding upon the parties and their respective heirs, administrators, personal representatives, executors, successors and assigns. You have the authority to release the Claims and have not assigned or transferred any Claims to any other party. The provisions of this Release are severable. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision. This Release constitutes the entire agreement between the parties and supersedes any prior oral or written agreements or understandings between the parties concerning the subject matter of this Release. This Release may not be altered, amended or modified, except by a written document signed by both parties. The terms of this Release shall be governed by and construed in accordance with the laws in your State.

    VII - PHOTOGRAPHY: You consent to the photographing and filming of the treatment or procedure for educational, diagnostic, or for other reasons deemed appropriate by Intravenous Queen.

    VIII - You have carefully read and fully understand all the provisions of this Release and am freely, knowingly and voluntarily entering into this Release.