I, the undersigned, desire to gain clinical experience as a medical student or resident at Mercy Medical Center, Cedar Rapids, IA, (“Mercy”) and engage in the activities related to that experience. I hereby freely and voluntarily execute this Release and Waiver of Liability under the following terms:
I understand that my participation may expose me to risks of bodily injury, personal injury, illness, death, or property damage. Further, I acknowledge that I may be exposed to risks that may not be foreseeable. I knowingly and freely assume all such risks and voluntarily participate.
I certify that, to the best of my knowledge, I am medically, physically, and otherwise able to participate in the activities required for this experience.
I understand that Mercy does not provide insurance coverage for me as a medical student or resident.
In consideration for being permitted to perform medical student or resident services, I, for myself, my heirs, personal representatives, and assigns, do hereby release, indemnify, and hold harmless Mercy Medical Center, and its respective officers, employees, agents, and volunteers, from and against any and all claims, demands, rights, expenses, and causes of action arising from or by reason of any personal injury, bodily injury, property damage, or the consequences thereof, whether foreseeable or not, resulting from or in any way connected with my participation as a medical student or resident.
I hereby release and forever discharge Mercy Medical Center from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my tenure as a medical student or resident with Mercy.
Further, I agree that I will not take legal action against Mercy Medical Center, its agents, or its employees for any claim for damages arising out of my participation in activities as a medical student or resident, whether caused by negligence or otherwise.
I consent to and authorize the use of my image (either still or motion picture), voice, and/or likeness by Mercy Medical Center through any media now and in the future. I understand that I will receive no compensation in connection with the use of my image, voice, and/or likeness.
By my signature below, I certify that I understand and have read the above carefully before signing.
My electronic signature will constitute my "original" signature as well as my Acknowledgement and Certification of the applicable statement(s) when used or printed. A copy of this form will be maintained in my medical student or resident file and I can receive a copy at any time from Mercy Physician Relations.