Release of Claims Form 1.15.26 ADA (locked)

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This sheet maybe used only when it accompanies and is affixed to the primary Release of Claims Form. I have read this release and understand all its terms. I execute it voluntarily, and with full knowledge of its significance. Name: [LAST] [FIRST] (M.1.] ❑ Adult Minor Signature: Date: if the Iparticipant its a_irniinoir,_Parent or Legal guardian shaRproviido_addiitiionai information as folios: Name: [LAST] Parent [FIRST] (M.1.] El Legal Guardian Signature: Date: I have read this release and understand all its terms. I execute it voluntarily, and with full knowledge of its significance. Name: [LAST] [FIRST] (M.1.] ❑ Adult Minor Signature: Date: if the Iparticipant its a_irniinoir,_Parent or Legal gUairdiian shaUproviido_add iitiionai information as folios: Name: [LAST] Parent El [FIRST] (M.1.] Legal Guardian Signature: Date: I have read this release and understand all its terms. I execute it voluntarily, and with full knowledge of its significance. Name: [LAST] [FIRST] (M.1.] ❑ Adult Minor Signature: Date: if the Iparticipant its a_irniinoir,_Parent or Legal guardian shaRproviido_addiitiionai information as folios: Name: [LAST] Parent El [FIRST] (M.1.] Legal Guardian Signature: Date: I have read this release and understand all its terms. I execute it voluntarily, and with full knowledge of its significance. Name: [LAST] [FIRST] (M.1.] ❑ Adult Minor Signature: Date: if the Iparticipant its a_irniinoir,_Parent or Legal guardian shaRproviido_addiitiionai information as folios: Name: [LAST] Parent El [FIRST] (M.1.] Legal Guardian Signature: Date: I have read this release and understand all its terms. I execute it voluntarily, and with full knowledge of its significance. Name: [LAST] [FIRST] (M.1.] ❑ Adult Minor Signature: Date: if the Iparticipant its a_irniinoir,_Parent or Legal guardian shaRproviido_addiitiionai information as folios: Name: [LAST] Parent El [FIRST] (M.1.] Legal Guardian Signature: Date: Page 2 of 2 Return completed form to the facility staff 01/2026