Medical Equipment Loan Closet

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MEDICAL EQUIPMENT LOAN CLOSET AGREEMENT & RELEASE FORM

Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number *

Email *

If different than above, name of the person physically picking up the equipment is responsible for return.

Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number

Relationship to applicant

I hereby acknowledge receipt of the following item(s) of medical equipment loaned to me by Joliet Township for the applicant’s sole use and that this equipment will not be loaned to anyone else. I acknowledge that this equipment will be used as it is designed to be used and that I will exercise ordinary and reasonable care thereof. Please check off items borrowed: *

I understand that this loaned equipment remains the property of Joliet Township and is available to me at no cost. I am able to use the equipment as long as needed and will promptly return back to the Joliet Township as soon as finished so that it will be available to others in need. I hereby forever release and discharge Joliet Township and its employees or agents from all liability, claims, demands, and actions that I may have for any injury to my person or my property that results from my use of the loaned equipment and therefore they will not be held responsible for any defect in the equipment or any accident or injury that may occur during or subsequent to the use of the equipment. I hereby waive any and all claims I may have against the aforesaid related to the use of the equipment.

Signature *