THIS AGREEMENT AND RELEASE FROM LIABILITY (the “Release”) is given on this ___ day of ________, 20___, by _________________________________(“Beneficiary”) in favor of ELLIE’S RAINY DAY FUND (“Ellie’s”), a 501(c)(3) organization, and any related parties, or their directors, officers, employees, affiliates and agents, and the heirs, executors, personal representatives, successors and assigns of each of them (“Ellie’s Parties”).
Beneficiary desires to receive veterinarian services for his/her pet and also desires to receive funds from Ellie’s in order to pay for those services. In exchange, Beneficiary freely, voluntarily and without duress, gives this Release under the following terms:
1. Voluntary Participation
I acknowledge that I have agreed to accept funds from Ellie’s in order to receive the services indicated above. I further agree that my eligibility to receive said funds or participate in services may be terminated at any time by Ellie’s.
In consideration of the opportunity afforded me to receive the funds and services noted above, I agree that I, my successors, assignees, heirs, guardians and legal representatives, will not make any claim against Ellie’s Parties, or any suppliers of any materials or equipment that are used for fulfillment of the services, any of Ellie’s volunteers or sponsors, or any other service recipients, for injury, death, or damage resulting from the act or omissions of any person or entity, however caused, arising from my participation in these services. I will further assume the complete risk of any activity done in violation of any rule or directive or instruction.
3. Media/Photographic Release
I do hereby grant and convey unto Ellie’s, permission to use my pet’s name, photograph and/or likeness, in addition to any statement(s) I make regarding my participation in the program in any and all of its publications in print, television, online (including without limitation, its websites or pages on Facebook or other social media sites) and any other media, without compensation to me. This consent is irrevocable and is without payment. The materials will become the property of Ellie’s and will not be returned. I waive the right to inspect or approve anything in which my pet’s name, photograph and/or likeness, or my own statement(s) appears, and I waive any right to royalties or other compensation arising or related to their use. *If you have any questions about this provision, please contact Ellie’s.*
All the personal information Beneficiary gives to Ellie’s will be kept confidential and will not be shared with anyone outside of Ellie’s without my consent, with the exception of materials defined in Section 3 above.
Each party agrees that this Release and any other documents to be delivered in connection herewith may be electronically signed with name typed below, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
6. Knowing and Voluntary Execution
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A CONTRACT AND A RELEASE OF LIABILITY BETWEEN MYSELF AND ELLIE’S PARTIES, AND I SIGN IT OF MY OWN FREE WILL. BY SIGNING THIS AGREEMENT, I CERTIFY THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER.
IN WITNESS WHEREOF, Beneficiary has executed this Release as of the day and year first written above.
Contact Number: ______________________________________________________________________