FS-5300-34 Assumption of Risk, Waiver of Liability, and Indemnity

FS-5300-34 (v 04-2016)

OMB Control No. 0596-0170 (Exp. XX/XX/20XX)

USDA-FOREST SERVICE
LAW ENFORCEMENT AND INVESTIGATIONS
RIDE-ALONG PROGRAM
ASSUMPTION OF RISK, WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT

The undersigned has made a voluntary request to ride as a guest in a vehicle assigned to the United States Department of Agriculture, Forest Service (Forest Service) and to accompany a member or members of the Forest Service Law Enforcement and Investigations (LEI) Staff during the performance of their official duties.

Assumption of Risk

The undersigned is aware that the work of LEI personnel is inherently dangerous and that he/she may be subjected to the risk of death, personal injury, or damage to his/her property by accompanying a member or members of the LEI Staff during the performance of their official duties. The undersigned voluntarily assumes the risk of death, personal injury, and property damage arising from or in any way connected with riding along in an LEI vehicle, including but not limited to the death, personal injury, and property damage caused by the use of weapons, the exchange of gunfire, the risk of high-speed travel or pursuit, unlawful acts or forcible resistance by law violators or suspected law violators, assault, riot, breach of peace, use of force, explosions, gas, electrocution or the escape of radioactive substances while accompanying a member or members of the LEI Staff during the performance of their official duties.

Waiver of Liability

The undersigned hereby agrees that the United States and its officers, agents, and employees shall not be liable to the undersigned or his/her estate, heirs, or assignees for the death of, personal injury to, or property damage sustained by the undersigned as a result of negligence of an officer, agent, or employee of the United States while the undersigned is accompanying a member or members of the LEI Staff during the performance of their official duties.

Hold Harmless and Indemnity

The undersigned and his/her estate, heirs, and assignees shall hold harmless and indemnify the United States and its officers, agents, and employees for any injury, loss, or damage the United States may suffer as a result of claims, demands, losses, or judgments, other than those caused by the negligence of the United States or its officers, agents, or employees, arising in connection with the undersigned’s accompanying any member or members of the LEI Staff during the performance of their official duties.

THE RIDER MUST COMPLETE THE FOLLOWING IN HIS/HER OWN HANDWRITING:

Have you read this form in its entirety? Yes No

Are you aware that by signing this form you are agreeing (1) to assume all risk of death, personal injury, and property damage, (2) to waive all claims against the United States for negligence, and (3) to pay the cost of defending the United States in any lawsuit and to pay any damages incurred by the United States in any lawsuit, other than those caused by the negligence of the United States, arising in connection with your accompanying any member or members of the LEI Staff during the performance of their official duties? Yes No

What is the reason you are requesting this ride?

     

Applicant 21 Years of Age or Older

_______________________________ ________

Signature Date

Print Name of Applicant

Applicant Under 21 Years of Age (signature of parent/legal guardian required)

_______________________________ ________ _______________________________ ______

Signature of Rider Date Signature of Parent/Legal Guardian Date

______________________________ _ _______________________________

Print Name of Rider Print name of Parent/Legal Guardian

WITNESS/USDA-FOREST SERVICE APPROVAL

_______________________________ ________ _______________________________ ______

Signature of Witness/Assigned Officer Date Signature of Witness/Assigned Officer Date

Print Name of Witness/Assigned Officer

_______________________________ ________ _______________________________

Signature of Immediate Supervisor Date Print Name of Immediate Supervisor

Paperwork Reduction Act Notice

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0596-0170. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 0.25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are required to obtain benefits. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the U.S.D.A. Forest Service email address [email protected] and include the OMB Control Number in the subject line.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service. The collection of this information is authorized by Privacy Act System of Records USDA/FS-33 – Law Enforcement and Investigation Records.