YOU EXPRESSLY UNDERSTAND AND AGREE THAT:
I UNDERSTAND THAT THE CITY OF CHICAGO HAS CREATED A REGISTRY FOR PERSONS WITH DISABILITIES OR SPECIAL NEEDS THAT MAY ASSIST POLICE, FIRE, AND OTHER PERSONNEL IN THE EVENT OF AN EMERGENCY. MY INFORMATION OR THAT OF PARENT, FAMILY MEMBER, OR WARD MAY BE INCLUDED IN THE REGISTRY ONLY BY COMPLETING THE ATTACHED FORM AND GIVING IT TO THE CITY OF CHICAGO.
THE CITY OF CHICAGO AND ITS OFFICERS, AGENTS, REPRESENTATIVES, AND EMPLOYEES ARE NOT RESPONSIBLE FOR DETERMINING WHETHER PROVIDING INFORMATION IS SUITABLE FOR MY PARENT, FAMILY MEMBER, WARD, OR ME; ONLY I WILL MAKE THAT DECISION. ALL INFORMATION IS VOLUNTARILY PROVIDED.
IF I AM SIGNING ON BEHALF OF A PARENT, FAMILY MEMBER, OR WARD, I REPRESENT THAT I HAVE LEGAL AUTHORITY THROUGH A VALID POWER OF ATTORNEY OR OTHERWISE TO DO SO.
I ALSO UNDERSTAND THAT CITY OF CHICAGO POLICE, FIRE, OR OTHER PERSONNEL WILL NOT SUPPLY A PARENT, FAMILY MEMBER, WARD, OR ME WITH PREFERENTIAL CONSIDERATION IN AN EMERGENCY BECAUSE I COMPLETED AND PROVIDED THE CITY OF CHICAGO WITH THE ATTACHED FORM.
I UNDERSTAND THAT BY COMPLETING THE ATTACHED FORM I AM PROVIDING HEALTH INFORMATION TO THE CITY OF CHICAGO. MY SIGNATURE BELOW INDICATES THE WAIVER OF MY RIGHT OR THE RIGHT OF MY PARENT, FAMILY MEMBER, OR WARD TO THE CONFIDENTIALITY OF THE INFORMATION GIVEN TO THE CITY OF CHICAGO. I UNDERSTAND THAT THE CITY OF CHICAGO WILL KEEP THE HEALTH INFORMATION CONFIDENTIAL AND WILL USE IT ONLY AS PERMITTED AND NECESSARY, WHICH MAY INCLUDE PUBLIC HEALTH ACTIVITIES.
I UNDERSTAND THAT I MUST UPDATE THE INFORMATION PROVIDED IF IT CHANGES OR AS REQUESTED BY THE CITY OF CHICAGO.
BY SIGNING BELOW, I RELEASE AND HOLD HARMLESS ON BEHALF OF MY PARENT, FAMILY MEMBER, WARD, OR MYSELF, THE CITY OF CHICAGO, ITS AGENTS, REPRESENTATIVES, AND EMPLOYEES FROM ANY LIABILITY OR POTENTIAL LIABILITY INCLUDING BUT NOT LIMITED TO ACCIDENTS, INJURIES, OR DEATH ARISING OUT OF OR RELATED TO THE INFORMATION I HAVE PROVIDED ON THE ATTACHED FORM REGARDLESS OF WHETHER THE CITY OR ITS AGENTS, REPRESENTATIVES, OR EMPLOYEES ACT NEGLIGENTLY.
I HAVE READ THIS WAIVER AND GENERAL RELEASE AND FULLY UNDERSTAND ITS TERMS AND VOLUNTARILY ACCEPT THEM OR ACCEPT THEM ON BEHALF OF MY PARENT, FAMILY MEMBER, OR WARD.