CADAVER EXAMINATION LIABILITY WAIVER
Under the direct supervision of Exempla EMS Staff, I understand that
I/my child, ______________________________, will be viewing a prepared, dissected
human anatomical specimen on _______________, 2009,
At: (select location)
Exempla Lutheran Medical Ctr.: 8300 West 38th Ave., Wheat Ridge, CO 80033
Exempla Good Samaritan Med. Ctr.: 200 Exempla Circle, Lafayette, CO 80026
I realize that the Exempla Cadaver Anatomy Program (the “Program”) is focused
on the study of human anatomy and physiology, and that reasonable precautions will be
taken to avoid any accident or injury to myself, my child and other observers as a result
of participation in this educational opportunity. I will at all times follow the direction and
instructions of the Exempla EMS Staff during the Program.
In the event of any accident or injury to myself, my child or other observers, I will
hold Exempla, Inc. and its officers, directors, employees and representatives harmless
from any and all and against any and all actions, claims and demands whatsoever,
including costs, expenses and attorneys' fees, related to or arising out of the Program.
I further understand that Exempla, Inc., including its officers, directors,
employees and representatives, are not responsible for any mental, emotional or
physical distress incurred by me or any other observer in association with the Program.
I understand that I/my child have the option of voluntarily leaving the Program if
the educational experience becomes in any way uncomfortable.
To the best of my knowledge, I am not familiar with any family member or friend
who has been a donor to the Colorado State Anatomical Board in the last two years.
Signature: __________________________
Parent/Guardian:_______________________
Date: __________________________