Release and Assumption of Risk

Here is a form you can use:

The undersigned is buying industrial, specialty, or medical gases from Mountain Aire Gas (the “Company”) which he/she will move by car or closed van. Company has told the undersigned that:

    1.    Putting gas cylinders in cars or vans can be dangerous and should be 
        avoided.

    2.    Gas cylinders must never be moved in closed spaces such as car trunks.

        — It is Extremely dangerous and could cause Explosion or Fire.

    3.    Gas cylinders should be moved in fixed upright position, with windows open 
        for ventilation.

    4.    If cylinders are moved on their side, they must be fastened so they can’t 
        move, with windows open for ventilation.

    5.    It would be safer to wait and move the cylinder(s) by open truck, or to let 
        Company do it.

    The undersigned still wants to carry the gas cylinder(s) by car or van now and for himself/herself and his/her employer (if any), the undersigned:

    Assumes the risk of bodily injury to the undersigned or others in the car or van, or of loss of or damage to the vehicle or other property, and

    Releases the Company and its employees, officers and directors from any liability for bodily injury or loss or damage to any property resulting from his/her transporting any gas cylinder(s) by car or van.

    Dated: ______________________

    Sign here: ___________________________________________

 

Mountain Aire Medical Equipment  
 • 1165 Valley St. • Colorado Springs, CO 80915
Telephone: 1-800-659-9110 • FAX: 1-800-576-5441 
©1989 Mountain Aire Medical Equipment