Health Resources for All Stages of Life

A Health Event for All Ages!

Saturday, April 2010 a.m. - 1 p.m.

Siloam Springs Regional Hospital • 603 N. Progress Ave.

Health Fair includes:

Vendor Expo Teddy Bear Clinic

Emergency Vehicles Kids Zone

Games & Inflatables Health Resources

And More!

Healthy Community Fair Participation Consent and Release Form

Consent Health Screening I acknowledge that I am voluntarily participating in a health screening sponsored by this facility and herein request and consent to the performance of diagnostic studies and examinations. I understand that the information derived from my participation is not a complete health examination, but it will provide certain information that needs to be further evaluated by my physicians. I certify that all of the information I have provided, or will provide, as part of said participation is true, correct, and complete to the best of my knowledge. I understand that the facility and the individuals providing the testing services undertake no obligation to follow-up or provide continuous services to me. I understand and accept the responsibility to follow up with my physician regarding the interpretation of these studies and examinations. I consent to the following services to be performed today: Blood sugar (a test done to measure the level of glucose in my blood to check for diabetes); Body Mass Index; Vital signs (blood pressure, pulse, temperature, respirations and/or oxemetry); Vision screening (eye chart only). I understand there are risks associated with health screenings, drawing blood or giving vaccinations, which include bleeding into the surrounding tissue, injury to the nerves at or near the site, or infection. X-ray imaging procedures carry the risk of radiation exposure, which in most examinations is very small. I understand I should not undergo any X-ray/imaging procedures if I am pregnant without the written consent of my physician. I agree for myself, my heirs, executors and administrators to not sue and to release, indemnify and hold harmless Siloam Springs Regional Hospital and their affiliates, officers, managers, directors, volunteers, and employees from any and all liability, claims, demands, and causes of action whatsoever, arising out of my participation, whether it results from the negligence of any of the above or from any other cause. This release and indemnification shall be as broad and inclusive as permitted by the State of Arkansas. If any portion is held invalid, the balance shall continue in full force and effect.

Endorsement/Photo/Video Release I authorize Siloam Springs Regional Hospital (“Facility”) to use my name, endorsement, testimonial, personal story, photographs (including but not limited to “Before and After” photos), likeness, and image, (all of the foregoing shall be collectively referred to by the term “Endorsement”), in connection with any marketing and/or advertising for that Facility, in its sole discretion, elects to conduct. I understand that Facility may elect to engage in such marketing and/or advertising campaigns via print, on the Internet, Web casts, CD/DVD ROM, over the airwaves, or through other communications media as Facility deems appropriate. I waive any and all rights and claims to remuneration or compensation for Facility’s use of my Endorsement, including but not limited to my rights of privacy and publicity. I agree that all photos, images, recordings or other materials comprising my Endorsement shall become the sole and exclusive property of Facility. In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my likeness or my testimonial appears. I hereby hold harmless and release The Company from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I understand that my Endorsement may benefit may generally benefit my community, and that the possibility of such benefit constitutes sufficient consideration for this Release. Facility is under no obligation to use my Endorsement should it decide, in its sole discretion, that my Endorsement is not suitable for use in its marketing and/or advertising campaign. I certify that all Endorsement materials that I submit to Facility are true and accurate. I further certify that I will not omit any facts from my testimonial or endorsement that a reasonable consumer would consider relevant when making the decision to utilize Facility’s services. To the extent that my Endorsement required the application of expertise, I certify that my qualifications provide the required expertise and that I have exercised my expertise to the degree necessary to support the conclusion in my Endorsement.

I have read, understand and agree to the terms of this Agreement. _________________________________________ ___________________________________________________ Print first and last name of guardian present Signature of Guardian / Parent _________________________________________ ___ Male ___ Female _____________ Date of Birth Phone Number ______________________________________ (City)_______________ (State)_____ (Zip)____________________ Address of Guardian / Parent Print first and last name(s) and ages of children present 1.__________________________Age: ______ 5.__________________________Age: ______ 2. __________________________Age: ______ 6.__________________________Age: ______ 3. __________________________Age: ______ 7. __________________________Age: ______ 4. __________________________Age: ______ 8. __________________________Age: ______ ____________________________ SSRH Employee Witness Signature April 20, 2019