Socorro's Place

Spanish Translation

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Guest Agreement and Release of Liability

I understand English (defined as a basic understanding of the language that will enable me to read and follow safety, facility, and operational instructions). If I do not understand English, it is recommended that I be accompanied by a person who understands the language.

Guest's Initials *

In consideration for being allowed access to Socorro's Place accommodations, I represent and agree to the following:

I.Socorro's Place Policies and Procedures:

a. I have received a copy of the Policies and Information. I have been oriented to, understand, and agree to comply with the policies contained in the Policies and Information as well as all other policies of Socorro's Place, including but not limited to those outlined in this Agreement.

b. I understand that the keys provided to guests of Socorro's Place are the property of GCAP and that these keys are not to be duplicated or given to unregistered guests. Ifroom/door keys are not returned or are lost during my/our stay at Socorro's Place I agree to pay for their replacement ($10 per key).

c. I understand that occupancy of each guestroom is limited to no more than two (2) guests.

d. I understand that Socorro's Place is smoke-free, with the exception of the designated smoking area in the backyard, and understand I will be responsible for a cleaning fee of $100 should I violate this policy. I understand that this rule includes the use of electronic cigarettes.

e. I understand that possession of alcohol, firearms, and weapons is not permitted at Socorro's Place and its surrounding grounds. Therefore I agree not to possess alcoholic beverages, firearms or weapons while on the premises or grounds of Socorro's Place.

f. I understand that meals should be taken in the kitchen and dining room areas and that only drinks and snacks are allowed in guest room. I further understand that I am required to keep empty drink and snack containers properly disposed of to help control pest control issues.

g. I understand that no pets (other than preapproved service animals) are allowed in Socorro's Place.

h. I understand that Socorro's Place reserves the right, in its sole discretion, and I hereby grant such permission to the management of Socorro's Place, to inspect guestrooms.

i. I understand that if I plan to leave Socorro's Place for more than two nights during my current stay while I am an eligible guest of Socorro's Place, I must inform Socorro's Placestaff before I leave and let them know when I will return.

II. Outpatient Guests

a. I understand that Socorro's Place is NOT a medical facility, and no medical treatment will be made available to me at Socorro's Place.

b. I understand that the management of Socorro's Place may require me to be accompanied by a full-time caregiver if, in the opinion of the management, I am unable to properly care for myself on my own.

c. I understand that my caregiver must receive the approval of the management of Socorro's Place to serve as a caregiver on Socorro's Place premises, and the caregiver must agree to the terms and conditions of this Agreement.

d. If a full-time caregiver is unavailable to me or if the caregiver I select is not acceptable to the management of Socorro's Place, or if the caregiver refuses to sign this Guest Agreement, then I will leave Socorro's Place and make other living arrangements.

e. I agree to vacate Socorro's Place no later than 24 hours following the completion of my treatment or doctor appointment.

f. If I become hospitalized for any reason while a guest at Socorro's Place, I understand that I have 72 hours from the first day of my hospitalization to check back into the facility. If after 72 hours I am not well enough to return to Socorro's Place and there is no other family member or caregiver using my assigned room, I understand that my room will be vacated and the room request canceled.

g. I understand that I must report to Socorro's Place staff if I present symptoms of a contagious disease such as, but not limited to, temperature, cough, vomiting, or diarrhea. To ensure the health of Socorro's Place and its occupants, I understand that I may be asked to find other accommodations until I have been symptom free for a period of 48 hours.

III. Duration and Revocability of Accommodations for All Guests

a. I understand that I am a guest of Socorro's Place and that my access to premises and use of Socorro's Place is revocable at any time.

Guest's Initials *

b. If at any time I no longer meet the Eligibility Requirements contained in the Socorro's Place Referral Form, I agree to inform Socorro's Place staff and to vacate the facility within 24 hours. If I am admitted on an as-space-allows basis, I agree to check availability with the staff daily by 9am and will be ready to vacate the facility by 11am if requested.

Guest's Initials *

c. I understand that noncompliance with rules and regulations in the sole and exclusive judgment and discretion of management of Socorro's Place may result in immediate revocation of this Agreement, termination of residentia laccommodations, and removal of me and my possessions from the premises.

Guest's Initials *

d. I understand that I am eligible to stay at Socorro's Place only between the start date and end date of the patient’s treatment plan as specified on the referral form submitted by the health care facility. If treatment is extended, I agree to provide an update of the expected discharge date and understand that Socorro's Place will verify the information with the health care provider. I understand that Socorro's Place is available to eligible guests for up to 28 days. After this time, I understand that Socorro's Place will review the patient’s status with the referring health care provider to determine if an extension will be granted.

Guest's Initials *

IV. Representations, Disclosures, and Affirmations

a. I confirm that I am free of any communicable or infectious diseases that may place other Socorro's Place guests, volunteers, or staff at risk. I will notify Socorro's Place staff and immediately leave the premises if I contract such a disease during my stay.

b. I have disclosed whether I am or will be receiving radioactive treatment.

c. I have never been convicted of a crime of violence, crime of theft, crime of domestic violence, crime against a child, or a crime involving illegal drugs; I am not required to register on the state’s Sex Offender Registry or the National Sex Offender Registry; noone has a civil protection order against me; and I am not currently under probation or on parole.

d. If I am a patient with pre-approval to stay without a caregiver, I affirm that I am able to secure emergency assistance and manage all other aspects of self-care while at Socorro's Place including, but not limited to loading/unloading vehicles, getting onto/off the shuttle,cooking, cleaning, and having the social skills necessary for living in a town home environment.

e. If I am a caregiver, I affirm that I am at least 18 years old. I affirm that I am able to stay with and properly care for the patient. My duties may include being able to secure medical assistance for the patient in case of emergency and manage all other aspects of caring for the patient while at Socorro's Place including, but not limited to,loading/unloading their vehicle, escorting the patient onto/off the shuttle, cooking,cleaning, and having the social skills necessary for living in a town-home environment.

V. Release of Liability

a. I understand that Socorro's Place may, at times, make certain third-party service providers(e.g. counselors, health/fitness instructors) available to guests. I understand that Socorro's Place does not directly endorse any of these service providers, nor does Socorro's Place make any guarantee of services, and DOES NOT ACCEPT ANY RESPONSIBILITY OF LIABILITY FOR ANY INJURIES OR DAMAGES WHATSOEVER ARISING OUT OF THE GUEST’S USE OF OR INABILITY TO USE THESE SERVICES. I understand that guests should always consult with their primary care physician before participating in any physical health/fitness exercise.

b. To the maximum extent permitted by law, I HEREBY RELEASE Socorro's Place, ITS OFFICERS, EMPLOYEES, AND AGENTS FROM ALL LIABILITIES, CAUSES OF ACTION, CLAIMS AND DEMANDS THAT MAY ARISE IN ANY WAY FROM ANY INJURY, ILLNESS, DISABILITY, DEATH, LOSS, EMOTIONAL DISTRESS OR HARM TO ME OR MY PROPERTY WHATSOEVER IN ANY WAY ARISING OUT OF MY PRESENCE AT Socorro's Place.

c. To the maximum extent permitted by law, I AGREE TO INDEMNIFY, DEFEND AND HOLD Socorro's Place, ITS EMPLOYEES, AGENTS AND CONTRACTORS<br>HARMLESS FROM AND AGAINST ANY AND ALL CLAIMS, DEMANDS, CAUSES OF ACTION, DAMAGES, LOSSES, EXPENSES, AND ATTORNEYS' FEES IN ANY WAY ARISING OUT OF MY PRESENCE AT Socorro's Place.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. No representations, statements, or inducements, oral or written, apart from the foregoing written statements, have been made regarding this Agreement or accommodations at the GCAP Socorro's Place. My decision to accept accommodations provided by the GCAP Socorro's Place is voluntary, and prior to signing this Agreement, I have had the opportunity to consult with the advisor, counselor or attorney of my choice. By signing below, I hereby certify that I have read this entire Agreement, that I understand its terms, that I am giving up legal rights that I might otherwise have, including the right to sue.

First Name *

Last Name *

Date *

Digital Signature *

Media Release *

I AUTHORIZE Socorro's Place to photograph me and to post my photograph and/or written comments I provide to Socorro's Place on Socorro's Place's website, newsletter, or other written or elec
I DO NOT AUTHORIZE Socorro's Plac eto photograph me and to post my photograph and/or written comments I provide to Socorro's Place on Socorro's Place’s website, newsletter, or othe

The following is my permanent address and contact information:

The address on the photo identification provided is my current mailing address. *

Yes
No

Address 1 *

Address 2

City *

State/Province *

Zip *

Email *

Phone *

Emergency Contact: Please provide contact information for one individual that may be contacted on your behalf in the event of an emergency.

Name *

Relationship *

Phone Number *

Timeout Warning

Socorro's Place

Guest Agreement and Release of Liability

I.Socorro's Place Policies and Procedures:

II. Outpatient Guests

III. Duration and Revocability of Accommodations for All Guests

IV. Representations, Disclosures, and Affirmations

V. Release of Liability