Loan Closet Form

Loan Closet Check Out/In Form

BVA Member(Required)

Date(Required)

Brighton Ambulance District Resident Name

Action Being Taken (Requested or Returned)(Required)

Please indicate if an items is being returned or loaned out:

Residents Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Residents Phone Number

Item Being Requested/Returned(Required)

Crutches

Cane

Walker (Standard Pattern)

Walker (Four Wheeled Pattern)

Wheelchair

Transport Chair

Knee Scooter

Please indicate what item(s) are being requested or returned?

Resident Consent/Notice(Required)

I agree to the Notice/Consent as listed out on this document:

NOTICE

All loaned materials must be returned within thirty (30) days of this date. Any loaned equipment that you would like to keep for a greater period of time may be renewed over the phone by calling (585) 271-2718 ext. 1

Wheelchairs on loan not returned by the due date are subject to a charge of $300.00.

By consenting to this, in consideration of the loan of equipment Brighton Volunteer Ambulance Inc., hereby covenants and agrees to release, and shall at all times indemnify, defend and hold harmless, Brighton Volunteer Ambulance, Inc. from and against any claim, lawsuit, liability, loss, damage, demand or charge whatsoever and wherever and whenever arising from the use of loaned equipment provided by Brighton Volunteer Ambulance, Inc. Checking acknowledges that Brighton Volunteer Ambulance, Inc. has provided such equipment at no suitable or appropriate for any particular purpose for which the noted may be borrowing said equipment.