Automated External Defibrillator (AED) Request Form Borrower DetailsLast Name(Required) First Name(Required) Address(Required) Street Address Address Line 2 City ZIP / Postal Code Phone(Required)Email(Required) Purpose for Loan(Required) WA State Driver's License #(Required) Requested Check-Out Date (MMDDYYYY)(Required) Requested Return Date (MMDDYYYY)(Required) I understand that AED pickup must occur Monday - Friday, 8:00 a.m. - 3:30 p.m. at the Administrative Office, 5300 NW Newberry Hill Rd, Silverdale.(Required) Yes I understand that a police report will be filed if I do not return the AED equipment.(Required) Yes Release of Liability(Required)READ CAREFULLY - THIS AFFECTS YOUR LEGAL RIGHTS In exchange for participation in the Automated External Defibrillator (AED) Loaner Program managed by Central Kitsap Fire & Rescue (CKFR) and use of any equipment provided, I, THE BORROWER NOTED ABOVE, enter into this “Release” and commit to return all equipment hereby stipulated and agree to the following: 1. I agree to observe and obey all terms and conditions, posted rules, regulations, and warnings, and further agree to follow any oral instructions or directions given by CKFR, or the employees, representatives or agents of the organization with regards to the use of the AED, any associated equipment and/or supplies that are provided by CKFR as part of this program. 2. I represent that I have obtained AED training and chest compression training (or have current CPR certifications). 3. I will return the AED to CKFR admin building located at 5300 Newberry Hill Rd by THE REQUESTED RETURN DATE NOTED ABOVE and understand that if the AED is not returned by this date, I authorize CKFR recuperate from me the full value of the loaned AED and associated equipment; this can include the expenses of collection or suit, including actual attorneys’ fees. 3. I recognize that there are certain inherent risks associated with the described activity/ equipment and I assume full responsibility for such risks, including but not limited to, personal injury to myself or others. 4. It is agreed that borrower, on behalf of itself, its successors and assigns, hereby agrees to indemnify, and hold harmless CKFR, its agents, officers, and employees, from any and all claims, demands, and damages, of any kind, of the Borrower or to third parties, persons or property as a result of the borrowing of an AED. This obligation shall extend to all claims, damages, and demands as well as costs of defense. 5. I further release and discharge CKFR, including but not limited to, its various departments, its officials, administrators, employees, agents, representatives, and volunteers for any injury, loss or damage arising from the use, malfunction, or failure of the “AED. or its included equipment or supplies”, whether caused by my actions, the actions of CKFR, or actions by third parties. 6. I recognize the AED, or its included equipment or supplies, is offered by CKFR “AS-IS”. CKFR makes no warranty, expressed or implied, as to its fitness of any use or purpose. The AED and related supplies may be examined by the borrower prior to acceptance. 7. I agree and acknowledge that I entered into this Waiver freely and voluntarily and had time to review it and all other forms and terms and conditions before signing. I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS AS DESCRIBED HEREIN. I agree to the Release of Liability Waiver
