Field Missions of Tennessee

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Waiver Forms

1. Purpose of Screening:

Field Missions of Tennessee (hereinafter "FMOTN") is a non-profit corporation which provides health education and screening services, and limited medical treatments to promote wellness and to make individuals more aware of their health status. FMOTN is not NOT AN URGENT CARE, PRIMARY CARE, OR EMERGENCY CARE SERVICE. In some cases, individuals may be referred to specific wellness resources. Regardless of whether an individual is referred to wellness resources, it is the responsibility of the individual to follow-up with their regular medical or dental care provider or with any other healthcare professional for additional testing or medical treatment.

2. Explanation of Screening and Associated Risks:

Health screenings will include one or more of the following tests from this non-exhaustive list:

Finger Stick Blood Sample (Necessary for Blood Sugar Testing and Lipid Profiling)
Blood Pressure Check
Heart Rate Check
Strength Testing
Calculation of Body Mass Index (Requires calculation of Height and Weight)

Health screenings may include counseling from the following health professionals:

Medical Provider (Physician or mid-level provider)
Dentist or Dental Hygienist
Pharmacist
Nutritionist

During the screening, you may experience one or more symptoms from this non-exhaustive list:

Abnormal Blood Pressure or Blood Sugar levels
Fainting
Fall which may or may not result in serious injury or death
Other serious health conditions or medical emergencies

Emergency personnel and equipment (e.g. AEDs) are not on site should these situations arise. You are strongly encouraged to ask questions of the screening staff if you do not understand the risks or procedures to be performed. Before receiving any of FMOTN services, you are encouraged to ask the provider about risks and potential issues.

3. Confidentiality and Use of Personal Information:

By participating in this health screening, including any health counseling or limited medical treatments, you are granting to Field Missions of Tennessee (FMOTN), located at 952 Mountain Top Lane, Cookeville, Tennessee 38506, permission to use any information gathered or collected by it, its providers, or its volunteers for program development, education, statistical analysis, and referral to outside medical or dental providers. Any personally identifiable health information obtained in conjunction with your health screening, to include counseling and limited medical treatments, will be protected and will only be used in accordance with this consent agreement and subject to any applicable laws or regulations governing the use of personal health information. Your information, in aggregate form, may be used for educational or statistical purposes so long as the data does not personally identify you.

4. Responsibilities of the Participant:

It is your responsibility to notify the screening staff about any of your medical conditions or allergies, as they may affect your ability to participate in this screening process.

5. Release of Claims:

In consideration of your participation in this health screening, you do hereby agree to assume all risks of injury or death to yourself. You represent that you have reviewed and fully understand the risks detailed in paragraph 2 of this document, and that you understand that other risks of injury or death may exist. You also understand that your screening results, including health counseling and limited medical treatments, are to be used for educational purposes only and are not designed to replace your primary care physician. Your evaluation by the medical provider (physician or mid-level provider), dental hygienist, nutritionist, registered nurse, pharmacist, or any other volunteer is solely for the purpose of using the information obtained to educate you regarding your health and wellness. If you have a disease or condition and/or receive abnormal screening results you should promptly consult with a physician. Your screening results will not automatically be sent to a healthcare provider on your behalf. Your signature below authorizes, Field Missions of Tennessee (FMOTN), located at 952 Mountain Top Lane, Cookeville, Tennessee 38506, to seek immediate medical assistance on your behalf if warranted. You expressly agree that Field Missions of Tennessee, located at 952 Mountain Top Lane, Cookeville, Tennessee 38506, and its providers, volunteers, personnel, and agents shall not be liable for any damages arising from personal injury or death to yourself even if such injuries or death shall be caused by ordinary negligence of Field Missions of Tennessee or any of its providers, volunteers, personnel, or agents. BY SIGNING THIS DOCUMENT, YOU HEREBY RELEASE FIELD MISSIONS OF TENNESSEE AND ALL OF ITS PROVIDERS, VOLUNTEERS, PERSONNEL, AND AGENTS, INCLUDING SUCCESSORS AND ASSIGNS, FROM ANY AND ALL DAMAGES, DEMANDS, CLAIMS, CAUSES OF ACTION, PRESENT OR FUTURE, DISCLOSED OR UNDISCLOSED, ANTICIPATED OR UNANTICIPATED, CAUSED BY OR RESULTING FROM THE NEGLIGENCE OF FIELD MISSIONS OF TENNESSEE OR ANY OF ITS PROVIDERS, VOLUNTEERS, PERSONNEL, OR AGENTS OR OTHERWISE ARISING OUT OF MY PARTICIPATION IN THE HEALTH SCREENING OR MY USE OR ATTEMPTED USE OF THE PREMISES, FACILITIES, OR EQUIPMENT. I acknowledge that this release shall not apply to any claims related to gross or willful/wanton/criminal/intentional acts of those who are otherwise released hereby. This agreement shall be binding upon the undersigned and my heirs, executors, and administrators.

6. Freedom of Consent:

You acknowledge that you have read this document in its entirety (or that it has been read to you) and that you fully understand and agree to the above. If you are under the age of 18, you agree not to participate in this screening without the written consent of your parent or legal guardian. Your permission to perform this health screening is given voluntarily and extends to all screening personnel. You understand that you may stop the screening process at any time, if you so desire. You also understand the attendant risks and discomforts and have had an opportunity to ask questions that have been answered to your satisfaction.

7. Severability Clause:

In the event that any court should conclude that any portion of this document is unenforceable or void, such a determination shall not affect the remaining provisions of the document, which shall survive such a declaration.

8. Release of Likeness/Image:

You agree to allow the Field Missions of Tennessee and its providers, volunteers, personnel, and agents to take your photograph or photographs either while you are at rest or while exercising or performing any activity related to the health screening. You further agree to allow the Field Missions of Tennessee to use any of your photographs for publicity purposes, including but not limited to advertisements. You grant permission for use of your photographs in written form, as well as digital form. You agree to the use of any likeness of yourself in connection therewith. By agreeing to this waiver, you release FMOTN to publish your image or likeness in formats such as paper, virtual presentation, video, and other similar formats.

9. Consent for Follow Up Care:

You agree to be contacted by one of our volunteer health professionals at scheduled times after your initial visit. You consent to sharing your contact information with FMOTN and the FMOTN volunteer staff.

The World Health Organization has characterized the COVID-19 virus, also known as "Coronavirus," as a pandemic. FMOTN wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. Individuals may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the volume of individuals on site, the characteristics of the virus, and the characteristics of certain healthcare procedures, there is an elevated risk of you contracting the virus simply by being at a FMOTN event.

Some exams can create fine water spray or "aerosols" which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure.

To provide a safe environment for our patients and volunteers, FMOTN follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. Should you experience symptoms during your presence at a FMOTN event, please notify a health care provider or other FMOTN professional volunteer.

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