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IN CONSIDERATION OF the risk of participating in the Hope The Mission (“HTM”) and the City of San Bernardino (“City”) Motel (hereinafter “motel” and “hotel” may be used interchangeably) Voucher Program (“Program”); and my desire to participate in said Program and being given the right to participate in the same;
IN CONSIDERATION OF permission to participate, I acknowledge that I have received, read, and understand the information included in this form. I agree to participate in the Program through case management and vocational intervention, abide by the rules, follow schedules, and perform responsibilities for successful involvement in the program. Furthermore, I acknowledge that I may be asked to move out of the Program if I do not abide by the conditions, information, and rules stated therein.
I/WE HEREBY ACKNOWLEDGE that my/our family will be guests of the Program. In consideration of being permitted to reside in the Motel, we (myself and all individuals enrolled in the Program with me), intend to be legally bound and hereby acknowledge and agree to the following:
Responsibilities (Initial next to each item):
1._____I understand that HTM will be in regular contact with me to assist with my service needs and I agree to work on longer-term housing goals while participating in this temporary Program. Refusal to work with my case manager will result in a major violation and removal from the Program.
2._____I understand that I am participating in a temporary voucher Program and that my participation in no way establishes my residency at the assigned hotel.
3._____I understand if I am contacted by law enforcement for any reason, I will immediately notify HTM.
If I am the subject of multiple law enforcement calls for service due to criminal activity or behavioral issues, I may be subject to removal from the Program.
5. _____ I understand that as a participant in the Program, my hotel room may be subject to 1-2 random room inspections per week.
6._____I agree to abide by all hotel rules and regulations including the 28 consecutive day limit for hotel stays.
7._____I agree to utilize the room provided to me for myself. I am the only approved household resident, and no other subjects will be allowed to stay in or occupy the hotel room. Unapproved guests found in the room will result in a minor violation and immediate removal of the guest.
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8._____If the hotel terminates my stay, I understand I may not receive another Motel voucher placement. Motel staff reserves the right to terminate my stay at any time due to a violation of Motel rules.
9. I understand I will be held responsible if I cause any property damage and may be asked to leave by motel management. The level of damage to the property will determine the level of violation (major/minor).
10._____I will not receive mail of any kind at the assigned hotel. Using the hotel’s address to receive mail will result in immediate removal from the Program.
Safety Mandates (Please initial next to each item):
1._____I agree to not participate in any unlawful activities including violence and drug-related activities such as but not limited drug use, possession, transport, purchase, or sale of any controlled substance in or near the unit. Violation of this safety mandate will result in a major/minor violation at the discrepancy of HTM staff.
2._____I agree to notify HTM if the police or ambulance are called to my unit for any reason. Violation of this safety mandate will result in a minor violation.
3._____I agree to use safe and respectful communication towards others, refraining from using derogatory or vulgar language.
4._____I agree to keep my noise level down between the hours of 10 pm and 7 am and will not disturb other hotel guests.
5._____I agree to keep my unit safe and clean and allow housekeeping staff to clean my room daily or on the agreed-upon schedule, dispose of garbage and waste properly, and store food properly.
6._____I agree to immediately notify the motel management of any maintenance issues such as plumbing or pest issues to ensure the matters are attended to.
7._____By signing below, I have reviewed and agree to each of the specified guidelines. I understand I may request a copy of the agreement from my case manager. I agree that I have been informed that my failure to meet any of the guidelines could result in my removal from the City of San Bernardino Motel Voucher Program.
Acknowledgment of Risk or Injury Possibility, As a participant in the program, I/we recognize the risk and acknowledge that there are certain risks of physical injury – including death, damages, property Page | 3 of 4
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damage, or loss – which we may sustain as a result of residing at ____________________________ and/participating in any and all activities connected with the program, or the use of the facilities or equipment.
Waiver of Claim for Injury Clause. I/We, for myself and all individuals enrolled in the Program with me, agree to waive and relinquish all legal and/or equitable claims that we may have for injuries or damages, including wrongful death, as a result of residing in/participating in the Program or activities or using the facilities or equipment, against the City of San Bernardino and its Mayor and City Council members, officers, agents, servants, employees, volunteers, and affiliates.
I/We HEREBY release and forever discharge the City of San Bernardino, a charter city and municipal corporation organized and operating under the laws of the State of California with its principal place of business at Vanir Tower, 290 N. D Street, San Bernardino, CA, 92401, and its Mayor and City Council members, affiliates, managers, members, agents, attorneys, employees, volunteers, heirs, representatives, predecessors, successors and assigns (collectively “City”), from any physical or psychological injury, including wrongful death, that I may suffer as a direct result of my participation in the aforementioned Program.
I/We hereby agree not to sue the City of San Bernardino, or its Mayor and City Council members, officers, agents, servants, employees, volunteers, or affiliates for any injuries or damages, including wrongful death, sustained as a result of residing in/participating in the Program or activities or using the facilities or equipment.
I HEREBY ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS “WAIVER AND RELEASE” AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE
THE CITY OF SAN BERNARDINO AND ALL OF ITS AFFILIATED, MANAGERS, MEMBERS, AGENTS,
ATTORNEYS, EMPLOYEES, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND
ASSIGNS, FORM ANY AND ALL LEGAL AND/OR EQUITABLE CLAIMS OR CAUSES OF ACTION, INCLUDING
WRONGFUL DEATH, AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE
HAVE TO BRING A LEGAL ACTION AGAINST THE CITY OF SAN BERNARDINO FOR PERSONAL INJURY OR PROPERTY DAMAGE.
To the extent that statute or case law does not prohibit releases for ordinary negligence, this release also extends to negligence on the part of the City of San Bernardino and its agents and employees.
I agree that this Release shall be governed for all purposes by California law, without regard to any conflict of law principles. This Release supersedes any and all previous oral or written promises or other agreements.
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THIS WAIVER AND RELEASE OF LIABILITY SHALL REMAIN IN EFFECT FOR THE DURATION OF MY
PARTICIPATION IN THE ACTIVITY, DURING THIS INITIAL AND ALL SUBSEQUENT EVENTS OF MY PARTICIPATION.
THIS AGREEMENT was entered into at arm’s length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both Participant, __________________________, and Hope The Mission agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase, or portion of this Release of Liability shall be determined to be unlawful or otherwise unenforceable, the remainder of this Release of Liability shall remain in full force and effect. If a court should find that any provision of this Releaes of Liability to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.
In the event of an emergency, please contact the following person(s) in the order presented:
EMERGENCY CONTACT CONTACT RELATIONSHIP CONTACT
TELEPHONE
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ __________________
I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. I CERTIFY THAT I HAVE READ THIS AGREEMENT, THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.
Participant(s) Name: ________________________________________ Participant(s) Name: ________________________________________ Participant(s) Address: _______________________________________ Signature: ________________________________________________ Page | 5 of 4
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Signature: ________________________________________________ Date: ____________________________