Passenger Air Transport Waiver of Liability        Today's Date

Pilots need to print this form and have patient sign. This form must be faxed to MedFlight Indiana office before flight departure. Fax (317) 290-8600.

MedFlight of Indiana, Inc.
, a non-commercial, non-profit, public charity, tax exempt under IRS code 501©(3) volunteer public service organization and its volunteer pilot(s).

Pilot _______________________________ Co-Pilot _____________________________

Hereby agree to provide the following passenger(s):

Patient _____________________________ Escort ______________________________

With air transportation, free of charge, for the passenger's conveniences in obtaining, assisting with or returning from medical treatment or diagnosis.

In consideration for receiving this air transportation free of charge, I agree to hold harmless MedFlight of Indiana and its volunteer pilot(s) from any and all liability. Including, but not limited to, liability for negligence, for any personal injury or property damage I might suffer and for any wrongful death action which my estate might otherwise bring arising out of such injury, while I am a passenger on the aircraft arranged by MedFlight of Indiana and flown by its volunteer pilots.

I understand it is my sole and exclusive responsibility to purchase any flight or accident insurance should I desire to be insured on this flight.

In the event that any portion of this agreement is held invalid, the remaining portions shall remain in full force and effect.

As evidenced by my signature below, I have read this agreement in its entirety and agree to its terms.

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Print Name - Patient

__________________________________
Signature

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Date Signed

__________________________________
Address

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Print Name - Escort

__________________________________
Signature

__________________________________
Date Signed

__________________________________
Address

Photo Release: I understand that in order to continue to provide its free community service, MedFlight relies upon contributions which are in part solicited through publicity. In order to contribute to their efforts, I grant MedFlight of Indiana permission to take and use my photograph for promotion and public relations, as indicated by my initials here.

Patient Initials __________ Escort Initials ___________                

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