EMS University

Falck Rocky Mountain

Non-Employee Observer Program

ASSUMPTION OF RISK, WAIVER, RELEASE & INDEMNIFICATION AGREEMENT

Falck Rocky Mountain Inc. (hereinafter referred to as Falck) provides medical transportation and/or
emergency response services and activities related thereto (hereinafter referred to as “Response
Services”). I, __________________________________________, [Print Name of Participant] living at
______________________________________________________________ [Insert Full Address] desire to
participate in, observe and/or otherwise take part in Response Services.
In consideration of Falck’s consent to allow me to participate in its inherently dangerous and risky
activity of Response Services, I hereby knowingly, freely and voluntarily agree as follows:
Representations. I represent to Falck that I am legally competent and age eighteen (18) or older and
my driver’s license number is __________________________, for the State of Colorado which states my
birth date as _____________________. I acknowledge that I am not an employee or agent of Falck. I
represent that I do not have a medical physical condition or infectious disease which could be triggered
by participating in Response Services. I understand that if I received a small pox vaccination that I may
be contagious for up to four (4) weeks after my inoculation and I specifically represent that I have not
had the small pox vaccination or it has been at least four (4) weeks from my inoculation.

Disclaimer of Warranty. I understand that each situation that Falck responds to is based on
incomplete and limited information provided often under extreme and emergency conditions and
which may or may not be ultimately accurate. Moreover, I understand that each situation will
contain unforeseen and unknown hazards, dangers and risks to me and to Falck. Falck’s Response
Services are based upon whatever current information is available, at the time of the Response
Services are provided so I expressly understand and agree that Falck makes no representation or
warranty expressed or implied, written or oral regarding Response Services to me and to what I
may or may not be exposed.

Assumption of Risk. I voluntarily and freely assume all risks in connection with the Response
Services, with full understanding that I may be exposing myself to extreme danger, emotional
trauma and other risks. I acknowledge that participating in Response Services may result in, but is
not limited to bodily injury, death, emotional trauma, burns, extreme noise, extreme lights and or
exposure to hazards and/or diseases like airborne or bloodborne pathogens, bacteria or other
harmful transmissions to me. Exposure to an airborne or bloodborne pathogen may result in the
transmission of AIDS, hepatitis, TB or other infectious diseases.

Endangerment. I AGREE TO FOLLOW ALL INSTRUCTIONS, PROCEDURES, MEASURES AND
DIRECTIONS GIVEN BY FALCK AND UNDERSTAND MY FAILURE TO DO SO MAY RESULT IN
PROPERTY DAMAGE OR INJURY OR DEATH TO ME OR TO A THIRD PARTY. I UNDERSTAND THAT
MY PARTICIPATION IN RESPONSE SERVICES MAY BE TERMINATED AT ANY TIME FOR ANY
REASON BY FALCK.

Insurance. I understand that I am completely responsible for all insurance coverage which I may
wish to purchase to cover my participation in the Response Services.
Confidentiality of Protected Health Information. During my participation in Response Services, I
acknowledge that I may be exposed to confidential information and/or Protected Health Information
(for example, patient identity, care and/or treatment information) as defined under HIPAA (referenced
below). I acknowledge that Falck and the activities involved in Response Services are subject to broad,
extensive and comprehensive privacy and confidentiality laws and regulations protecting patient care
information. I understand that I am legally obligated and personally responsible for holding this
information confidentially and not disclosing it to anyone unless such disclosure is permitted under the
Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. § 1320d through d-
8 (“HIPAA”), the Health Information Technology for Economic and Clinical Health Act of 2009, and any
current and future rules and regulations promulgated thereunder, including without limitation, the federal privacy regulations as contained in 45 C.F.R. Parts 160 and 164, the federal security regulations
as contained in 45 C.F.R. Parts 160, 162 and 164, and other federal or state privacy laws.

Information regarding a patient is strictly confidential, its disclosure to anyone not specifically
permitted is strictly prohibited by law.
I specifically agree to: review Falck’s HIPAA Policies prior to my participation in the Response
Services; not to take, copy or disclose to the media or anyone any information I receive, observe,
view and/or otherwise have access to arising out of, in any manner whatsoever, may participation
in Response Services, unless required by law and you have provided notice to Falck of the request
prior to disclosure; adhere to HIPAA and other federal and state privacy laws and regulations;
keep all Protected Health Information as defined by HIPAA confidential; and not to disclose any
Protected Health Information and/or other confidential information unless so permitted under
applicable law.

WAIVER, INDEMNITY & RELEASE
I hereby waive, release and discharge Falck, its parent, subsidiaries and affiliates, and its and their
respective officers, directors, stockholders, employees, agents, representatives, insurers,
successors an assigns, of and from any cost, expense, claim, demand, right or cause of action, or
any kind or nature whatsoever, whether based on tort, contract, warranty, or other theory of
recovery, at law or in equity, vested or contingent, that I or my spouse, family, parents, children,
estate, heirs, agents, insurers, successors or assigns may at any time have as a result of the
Response Services for Falck. In addition, I hereby agree to save, hold, defend and indemnify Falck,
its parent, subsidiaries, and affiliates, and its and their respective officers, directors,
stockholders, employees, agents, representatives, insurers, successors an assigns, of and from any
cost, expense, claim, demand, right or cause of action, or any kind or nature whatsoever, whether
based on tort, contract, warranty, or other theory of recovery, at law or in equity, vested or
contingent, that may result, directly or indirectly, from my action or inaction, including my
participation in Falck Response Services.

I UNDERSTAND THAT THIS WAIVER, RELEASE AND INDEMNITY IS INTENDED TO WAIVE,
RELEASE, DISCHARGE AND INDEMINIFY IN ADVANCE FALCK, ITS PARENT, SUBSIDIARIES AND
AFFILIATES, AND ITS AND THEIR RESPECTIVE OFFICERS, DIRECTORS, STOCKHOLDERS,
EMPLOYEES, INSURERS, AGENTS, REPRESENTATIVES, SUCCESSORS AND ASSIGNS, FOR, FROM
AND AGAINST ANY AND ALL LIABILITY TO ME ARISING FROM THE RESPONSE SERVICES FALCK
IS INVOLVED IN. THIS INCLUDES, WITHOUT LIMITATION, ANY LIABILITY (INCLUDING
CONSEQUENTIAL, INDIRECT, SPECIAL OR INCIDENTAL DAMAGES) ARISING FROM INJURY OR
DAMAGE THAT I SUFFER OR CAUSE DURING THE RESPONSE SERVICES INCLUDING, WITHOUT
LIMITATION, DEATH, INJURY, EMOTIONAL TRAUMA, BURNS, ILLNESS, DISABILITY, EXTREME
LIGHTS, EXTREME NOISE OR OTHER DAMAGE TO MY PERSON AND/OR PROPERTY OR THIRD
PARTY, AND ALL RISKS CONNECTED THERETO, WHETHER FORESEEN OR UNFORESEEN,
RESULTING FROM NEGLIGENCE OR OTHERWISE.

I agree that this Waiver and Release is intended to be as broad and inclusive as permitted by the laws of
the State of Colorado. If any provision of this Waiver and Release shall ineffective or invalid, such
provision shall be ineffective or invalid only to the extent of such prohibition or invalidity, without
invalidating the remainder of such provision or the remaining provisions of this Waiver and Release,
which shall remain in full force and effect.

Duty to Inform. So long as I participate in Response Services, in the event any representation or
obligation of mine in this Agreement is no longer accurate, or true, I agree to inform Falck
immediately in writing of such occurrence. I realize that Falck is relying upon my representations and agreements made in this Agreement and that my failure to adhere to this Agreement could
seriously injure someone, cause their death or damage property.

I HAVE READ THIS AGREEMENT AND THE WAIVER, RELEASE AND INDEMNITY BEFORE SIGNING
IT, AND FULLY UNDERSTAND AND AGREE TO ITS TERMS.

AGREED AND ACCEPTED:

Falck Rocky Mountain, Inc.
By (signature): ______________________________
Printed Name: ______________________________
Date: ________________________

Request for Ride Along