There are two steps to becoming a volunteer for Neurogel en Marche - USA sponsored human clinical phases. The first step is to sign the release form below. These volunteers for the Clinical Phases will then be provided a screening criteria document (Step 2). This screening document will be used by Neurogel en Marche - USA to determine who will have priority for acceptance into the human trial phase. Each participant will be given written information describing the nature and duration of the trial. This information will be provided so the participant has adequate time to consider how much time they will be asked to devote to completing the trial and the risks associated with their participation in the trial. The goal of Neurogel en Marche - USA is to cover whatever costs associated with the trial (preparation, surgery and rehabilitation therapy) the participant is unable to cover by medical insurance, donations or grants.
Release and Waiver for NeM - USA Program
Volunteer for Clinical Trial Phases
I, the undersigned, intending to be legally bound for myself, my spouse, my children, legal representatives, successors and assigns do hereby:
1. acknowledge that my participation in the NeM - USA, Inc program exposes me to possible injury and I fully assume all risks inherent in my participation.
2. release and agree to indemnify the NeM - USA, Inc and anyone associated or affiliated with this corporation from any and all liability, loss damage, expense, or cost of any kind of nature whatsoever from any and all claims for property damage, personal injury and/or any other claims arising from my participation in the program, including claims that are known or unknown, foreseen or unforeseen, future or contingent.
3. covenant that I shall not now or at any time in the future, directly or indirectly, commence or prosecute any action, suit or other proceeding against NeM - USA, Inc and anyone associated or affiliated with this corporation arising out of, relating to, or in connection with the actions, causes of action, claims and demands hereby waived, released or discharged by me.
4. attest that I am aware of the extent of the requirements associated with the NeM – USA program and that I am physically fit to participate; and
5. consent to receive medical treatment in the event of injury, accident, and/or illness during my participation in the program.
6. understand that if accepted to participate in NeM - USA sponsored clinical trials or treatments that a signed informed consent will be obtained from each volunteer patient prior to the trial. Each participant will be given written information describing the nature and duration of the trial. This shall take place under conditions where the participant has adequate time to consider the risks associated with their participation in the trial. Two copies of the informed consent will be signed: one will be given to the participant and to the principal attending physician. Other appropriate consent and waiver forms will be accomplished with specific institutions or organizations participating in the clinical trial
I have read the foregoing and I fully understand and agree to it.
Name (please print) ____________________________________