PG&E Breast Pump Waiver & Release of Liability Form - MyPGEBenefits

PG&E Breast Pump Waiver & Release of Liability Form - MyPGEBenefits

PG&E Breast Pump Waiver & Release of Liability Form  PG&E provides a breast pump located in each of its designated Mothers’ Rooms to assist breastfeed...

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PG&E Breast Pump Waiver & Release of Liability Form  PG&E provides a breast pump located in each of its designated Mothers’ Rooms to assist breastfeeding  employees with milk expression during work hours. This multi‐user hospital‐grade Ameda Elite or Medela  Symphony pump can be used by more than one employee and it is the employee’s responsibility to bring their  own pump attachment parts. Employees who use this breast pump must complete this waiver form and submit  it to [email protected] prior to use.  

  1. Name (print first and last)    3. Work Phone   

2. LAN ID  4. Cell Phone (optional)   

5. Address (primary office) 

6. City, Zip Code 

 

 

7. List primary locations of Mothers’ Rooms you plan to use:        

WAIVER AND RELEASE OF LIABILITY    

I, _______________________________ (hereinafter “Releasor”), the undersigned, with the intent of  binding myself, my spouse, my heirs, legal representatives and assigns, execute this Release as my own  free act and deed.    Releasor, being of lawful age, in consideration of being permitted to utilize the breast pump  (hereinafter, “Breast Pump”) provided by Pacific Gas and Electric Company in common areas referred  to as “Mothers’ Rooms” do for myself, my spouse, my heirs, legal representatives and assigns, hereby  release and forever discharge Pacific Gas and Electric Company, its parents, subsidiaries, affiliates,  officers, directors, stockholders, heirs, employees, executors, administrators, or legal representatives,  or other successors in interest and each of them (hereinafter “Releasees”), from any and every claim,  demand, action or right of action, of whatever kind or nature, either in law or equity, arising from or by  reason of usage of the Breast Pump. Releasor waives the right to bring suit for and hereby assumes all  risks of any bodily injuries, death, or property damage that may occur during or as a result of  Releasor’s usage of the Breast Pump, whether caused by negligence of Releasees or otherwise.     Releasor further releases Releasees and any professional person of any claim whatsoever on account  of first aid, treatment or services rendered to her in connection with her use of the Breast Pump.    Releasor further warrants and states that:    1. Releasor is aware and acknowledges that usage of the Breast Pump is completely voluntary.    2. Releasor has consulted with her physician or healthcare professional before using the Breast Pump,  including discussion of any pre‐existing medical conditions that may affect whether or not Releasor should  use the Breast Pump, and has been provided with medical clearance to use the Breast Pump.  Releasor has  not relied upon any statements from or information provided by Releasees in deciding whether or not to  use the Breast Pump. 

3. Releasor has read and understands the “Ameda Elite Breast Pump Instructions” and/or “Medela  Symphony Instructions for Use” located in the Mothers’ Room for the Breast Pump prior to using the Breast  Pump. Releasor understands how to turn the Breast Pump on and off and how to safely operate the Breast  Pump.    4. If Releasor has any concerns about her own health or the health of her child, Releasor will consult with  her physician or other healthcare provider regarding those concerns.    5. Releasor will visually inspect the Breast Pump for any obvious signs of malfunction or unsanitary  conditions prior to each use of the Breast Pump. If Releasor observes any suspected signs of malfunction or  unsanitary conditions, she will refrain from using the Breast Pump and immediately notify  [email protected]    6. Releasor is responsible for providing her own pump attachment parts. Releasor is solely responsible for  maintaining the working condition and sanitation of such parts.    7. If Releasor sustains any injury as a result of using the Breast Pump, Releasor will call PG&E’s 24/7 Nurse  Care Hotline at 1‐888‐449‐7787 to report the injury as soon as feasible. If the injury is severe and warrants  immediate medical attention, Releasor will call 911 prior to calling the Nurse Care Hotline.        8. After each use, the Releasor will use the provided anti‐microbial wipes to clean the Breast Pump, and the  area around the Breast Pump, as needed.    9. Releasor will immediately stop use of the Breast Pump if she experiences pain, dizziness, fever,  inflammation, or any other symptoms that cannot be explained.    10. Releasor is responsible for the proper storage of her expressed milk. If Releasor uses the company‐ provided refrigerator for storing her milk, it is recommended she label it with her name and the date the  milk was expressed.     11. Releasor has read this document, understands its contents, and understands that this is a waiver and  release of liability. Releasor voluntarily agrees to this waiver and release of liability. Releasor further  understands this waiver and release expressly waives all rights under Section 1542 of the California Civil  Code, which reads as follows:     A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR  SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF  KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.      

       

Date:          _______________________     Signature: _______________________________________________      

[updated 1/25/18]