FUNCTIONAL ASSESSMENT TEST CONSENT AND RELEASE I understand that prior to beginning employment I will be requested to take a post-offer functional assessment test. Any cost to conduct this test will be the responsibility of Ageia Health Services. The results of this test will be reviewed by a certified physical therapist. I acknowledge and agree that the Company’s offer of employment will be conditioned upon the results of this functional assessment. I understand that a favorable test result is not a guarantee of employment. I understand that this test will be performed by either the Company Registered Nurse or a certified physical therapist and I give full permission for the release of my results to the designated Ageia Company Representative. I hereby release Ageia Health Services and/or its affiliates, including evaluation and examination companies and/or entities, company employees, officers and directors from any and all liabilities and claims related to or arising out of any functional assessment to which I am required by the company to submit. I will hold all parties harmless and will not sue nor hold this company responsible for any alleged harm to me or for interfering with my obtaining a job or continued employment due to a refusal of testing or as a result of my test findings. This includes, but not limited to possible clerical or evaluation error. I have read the above consent and release document and acknowledge that I fully understand the contents and its purposes. I have been encouraged to consult with any member of the Company’s management about any questions I may have regarding the terms of this consent. I acknowledge and agree that this consent and release agreement contains the entire understanding and agreement between the parties and that all other representations, assurances, and promises, either oral or written, not incorporated or contained herein, are void and of no force and effect. If any term or provision of the consent and release agreement shall to any extent be determined to be invalid, illegal, or unenforceable, the remainder of this agreement shall not be affected. Each term of this Agreement shall be valid and enforceable to the fullest extent consistent with applicable law and this agreement shall be interpreted and construed as though the invalid, illegal, or unenforceable term or provision were not contained in this agreement. I have read, understand, and agree to the terms of the consent and release and understand that it is a complete expression of this agreement. I understand that there are no verbal promises or understandings pertaining to this agreement other than those specified. I agree that any amendments or modifications to this agreement must be in writing and signed by the Company President. I acknowledge receiving a copy of this agreement and I will abide by the terms. Company/Community Name: _____________________________________________ (Please bill testing services to the company listed above) ________________________________________________ Applicant Signature
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________________________________________________ Applicant’s Printed Name ________________________________________________ Employer Representative Signature
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