Digital TV: Keeping Seniors Connected Campaign
sAMPLE Waiver of Liability
DIGITAL TV CONVERSION ASSISTANCE
WAIVER OF LIABILITY
I, ______[print name of recipient], give permission to have a digital TV converter box installed at my home by trained staff/volunteers involved in the Digital TV: Keeping Seniors Connected Campaign. I understand the work will be performed by staff/ volunteers of the [insert name of agency here]. I understand that [insert name of agency here] has provided local/state criminal background checks and training on digital TV conversion.
In consideration of the installation of the converter box at ______[print address of the recipient], I ______[print name of recipient], agree to indemnify, hold harmless, and release [insert name of agency here], its staff/volunteers, agents and/or officials from any and all actions, causes of actions, claims, suits, or demands resulting from any act or omission arising out of the installation of the converter box.
No warranty, either expressed or implied, is intended to be created by the installation of the converter box.
To express my understanding of this Release, I sign here with a witness.
Recipient Name (Please Print) / Staff/Volunteer Name (Please Print)Signature of Recipient / Signature of Staff/Volunteer
Date
<Insert agency logo here>