Dignity of Risk Form

Activity Risk Assessment

Who has been involved in the risk assessment and discussion (add names in relevant rows)

I agree to indemnity and hold blameless Right at Home, it’s Franchise Owners, Vendors, Managers, Nurses, Allied Health Professionals, Care Workers, Staff, Agents, Contractors, or any other worker engaged by a Right at Home Office, collectively referred to as employees, from all claims, damages, losses, injuries and expenses arising out of or as a result of my participation in The Activity. This indemnification extends to all claims made by any other person against Right at Home and employees, in respect of any injury, loss, or damage arising out of or in connection with my participation in ‘The Activity’.

1. I acknowledge that:
   I am the Participant/Client
2. The Activity’ without supervision may be detrimental to my health/safety and could involve significant risk of harm.
3. Participation in ‘The Activity’ is of my choosing and I have not been required by Right at Home to engage in ‘The Activity’.
4. I have not relied upon any advice, representations or inducements by or on behalf of Right at Home to:
   a. Agree to participate in ‘the Activity’ as described in Section 3 of this document
   b. Sign this document.
5. I agree to indemnify and hold blameless Right at Home, it's servants, employees and agents from all claims, damages, losses, injuries and expenses arising out of or as a result of my participation in The Activity. This indemnification extends to all claims made by any other person against Right at Home, its servants, employees or agents in respect of any injury, loss, or damage arising out of or in connection with my participation in ‘The Activity’.
6. I acknowledge that I have read this form in full and that it has been explained to me. I acknowledge that I have been given the opportunity to obtain independent legal advice in respect of this document. I fully understand its intent and that I have given up substantial rights by signing it. I signed the document freely and voluntarily without any inducement made to me.

1. I act on behalf of the Participant/Client noted on this form.
2. I request that Right at Home support the Participant/Client to participate in The Activity as described within section 3 of this document.
3. I agree to indemnify and hold blameless Right at Home, it’s Franchise Owners, Vendors, Managers, Nurses, Allied Health Professionals, Care Workers, Staff, Agents, Contractors, or any other worker engaged by a Right at Home Office, collectively referred to as employees from all claims, damages, losses, injuries and expenses arising out of or as a result of my participation in The Activity. This indemnification extends to all claims made by any other person against Right at Home, its servants, employees or agents in respect of any injury, loss, or damage arising out of or in connection with my participation in ‘The Activity’.
4. By signing this document, I state that I have been provided information about the risks of this decision, I have been given ample opportunity to ask questions and I understand what I have been told. I acknowledge that I been given the opportunity to obtain independent legal advice in respect of this document.