Support Group Interest Form

Fields marked with an * are required

(I give my permission to release my(our) names, telephone number and other relevant information to Hazael Haven's Support Group Facilitator and Co-Facilitator and necessary Staff in order to arrange the services I have requested).

I do herby desire to participate in the Support Programs offered by Hazael Haven and any and all activities offered by Hazael Haven in connection with the same.

In consideration of my participation in the Support Programs, I, on behalf of myself, my heirs, assignees and personal representatives, voluntarily and with knowledge, hereby assume any and all risk of accident or damages, physical or mental, to my person or my property which may be incurred from or be connected in any manner with my participation in the Support Group. I further hereby release and forever discharge its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates and other participants from any and all liability, claims, demands, actions, causes of action, loss, injuries, costs or expenses, including attorney's fees, that may arise from my participation in the Support Group. I further waive and promise not to sue upon any claims, arising pursuant to statute or under common law against Hazael Haven, its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates and other participants, arising directly or indirectly from or attributable in any way to any negligence, action, omission or failure to act by any such person or organization with regard to any and all activities associated with the Support Group.

I hereby assume full responsibility for and risk of bodily or emotional injury, death or property damage due to the acts, failure to act, negligence, conduct or intentional torts of Hazael Haven its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates and other participants, while on the premises of the same or while observing, working for or in any way participating in the above-described any and all activities associated with or offered in connection with the Group.

I expressly acknowledge and agree that the activities of the above-described event may involve the risk of serious physical, emotional and/or psychological injury to myself and/or damage to my property. I further agree that the foregoing release and waiver is intended to be as broad and inclusive as is permitted by the laws of the State of Pennsylvania and that if any portion of it is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have read and voluntarily sign this Release and Waiver of Liability and further agree that no oral representations, statements or inducements apart from the foregoing written agreement have been made.