I, ________________________, HEREBY WAIVE AND RELEASE, indemnify, hold harmless and forever discharge Yale Record Therapeutic Services and its agents, sponsors, promoters, first cousins, officials, participants, employees, suitemates, officers, directors, mascots, professors, affiliates, second cousins, successors, members, trustees, alumni, managers and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to my participation or care received in any of the events or activities, conducted by, on the premises of, or for the benefit of, Yale Record Therapeutic Services. This waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct UNLESS said acts get a lot of traction on Yale Record socials.

I give my permission to my care management team, including any specialists, associates, assistants I am referred to or supported by, to make necessary decisions regarding first aid decisions in the event of an emergency during my treatment and/or adjustments to unrealistic or impossible life goals, especially if they are to result in further injury (physical or ego).

I agree to contact my care team in the event that I: feel my condition has worsened, begin to suffer from side effects from any prescribed medication, find myself talking and/or acting more like Tony Soprano or any of his cohort at the Bada Bing! strip club, develop an Oedipus complex, request “real” therapy, or participate in or organize other delirious actions.

In the event of a natural disaster, act of war, or other circumstance that may cause Yale Record Therapeutic Services to evacuate their building or relocate, I agree to temporarily loan out my current home, couch, and fridge for a period not to exceed 72 hours or the length of time before Yale Record Therapeutic Services finds a new location, whichever condition is longer.

I have read, understood, and fully agree to the above terms of this WAIVER AND RELEASE. I understand and confirm that by signing this WAIVER AND RELEASE I have given up considerable future legal rights, including mineral rights to my home and community, as well as my second-born child. I have signed this Agreement freely, voluntarily, under little threat of duress, without inducement, promise or guarantee being communicated to me.  My signature is proof of my intention to execute a complete and unconditional WAIVER AND RELEASE of all liability to the full extent of the law.  I am hopefully 18 years of age or older and mentally competent to enter into this waiver. This agreement has no cash value (but may be used as a non-fungible token as Yale Record Therapeutic Services seeks to get into that space).

DATE                ________________________

SIGNATURE            ________________________

PRINTED NAME                ________________________

MOTHER’S MAIDEN NAME    ________________________

FIRST PET            ________________________

HOMETOWN            _______________________

MAIL COMPLETED FORM TO

Yale Record Therapeutic Services
305 Church Street
New Haven, CT 06511


—T. Schroder

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