Washoe County Nevada Cares Campus -- WAIVER OF RIGHTS, RELEASE OF LIABILITY, AND CONSENT OF INFORMATION PACKET

THIS IS A LEGAL DOCUMENT AND COMPLETE RELEASE OF LIABILITY. PLEASE READ IT BEFORE SIGNING.

By signing this Waiver of Rights and Release of Liability, I hereby agree to the following:

• I certify that I am over 18 years of age.

• I certify and promise that I will hold Washoe County, Volunteers of America, Karma Box Project, and Allied Universal
harmless, and fully and forever release and discharge Washoe County along with its respective departments, directors,
officers, employees, agents, contractors, and any individual associated with the Nevada Cares Campus, from any and
all liabilities, claims, demands, damages, actions or causes of action arising out of or related to my participation in the
Nevada Cares Campus. I understand that this release of liability includes any damage to or destruction of my personal
property, as well as any personal injuries or death to me, whether or not such damage, destruction, injury, or death is
caused or alleged to be caused by the negligence, active or passive, of the released parties. I also understand that this
release of liability includes, but is not limited to, any claim, demand, action or cause of action which might be caused
by Washoe County, Volunteers of America, Karma Box Project, and Allied Universal or their respective departments,
directors, officers, agents and/or employees’ acts or failures to act.
• I acknowledge that the rights I am waiving and the release of liability that I am making apply equally to me and to my
heirs, successors, executors, assigns, guardians and legal representatives. I agree that none of those persons may make
any claim or take any action that I could not make or take myself.
This Waiver of Rights and Release of Liability is given in consideration Washoe County, Volunteers of America, Karma Box Project,
and Allied Universal and their respective departments, directors, officers, agents and employees permitting the undersigned to
become a participant at the Nevada Cares Campus.
I, the undersigned, have read this Waiver of Rights and Release of Liability and understand all its terms. I hereby execute it
voluntarily and with full knowledge of its significance.
Please initial by the following to indicate your agreement:

_____ I hold harmless and fully release and discharge Washoe County, Volunteers of America, Karma Box Project, and Allied
Universal, and its respective departments, directors, officers, agents, employees and/or contractors for any liability pertaining
to the loss or destruction of personal property that I may experience at the Nevada Cares Campus or on the Nevada Cares
Campus grounds.

_____ I agree that in the event I am unable to provide informed consent for emergency medical treatment, the Nevada Cares
Campus is authorized to arrange for such treatment by a licensed physician, including calling 911 and/or transporting me to
the nearest available medical site.

_____ I understand that the data collected during intake is for demographic, tracking and case conferencing for housing
placement purposes and will be shared with the contracted operator and relevant staff. Information collected during the
intake process will also be entered into the Homeless Management Information System (HMIS).

_____ I understand that background checks are not conducted on program participants and there may be Nevada Cares
Campus participants that have criminal convictions including sex offenses.
Participant Signature: _____________________________________________________ Date: _____________

Printed Name of Participant: _______________________________________________

Witness Signature: _______________________________________________________ Date: _____________

Printed Name of Witness: _________________________________________________

Updated: 9/12/22
 Important Information for Nevada Cares Campus Participants
Washoe County Office of the County Manager welcomes you!
The Nevada Cares Campus is designed to provide a safe and stable environment where people who are experiencing
homelessness are treated with dignity and respect while engaging in housing focused conversations, service referrals and
housing placements.
Every resident is expected to:
• Complete intake process with staff, including a commitment to pursuing stable, permanent housing as soon as possible.
• Promote peace and wellbeing for all guests, address conflict non-violently and engage in community building activities
Every resident is expected to uphold the following basic guidelines:
• No violent behavior; physical assault; threats; aggressive, violent, or inappropriate behavior or words, including but not
limited to, racist or discriminatory language and/or behavior toward a person on the basis of that person’s sex, sexual
orientation, gender expression and/or identity, race, religion, color or national origin, age, or disability; harassment;
stalking; intimidation; retaliation; blocking movements; gang related behavior; domestic violence; sexual harassment or
unwanted sexual advances (physical, visual, verbal, electronic, etc.)
• No behaviors associated with sex trafficking or recruitment of other individuals into sex trafficking.
• Possession of or use of weapons, firearms, ammunition, explosives, fireworks, or other dangerous substances or materials
of any kind
• Possession, use, sale, or purchase of illicit or illegal drugs, alcohol, or related paraphernalia is not permitted
• Theft or intentional destruction of property is prohibited
• No Fires, smoking is only allowed in designated areas
• No Disruptive Behavior - quiet hours from 10 pm-6 am
• Follow all emergency orders currently in place such as practicing Social Distancing, handwashing, wearing a mask in
communal spaces, and maintain 6ft of distance between self and others
• No videotaping, recording, or photographing other participants in any fashion
• Must agree to receive medical treatment when appropriate
• Keep permitted pets on a leash and clean up after pets
• Report violations of guidelines to staff

Length of Stay: Participants staying at the Nevada Cares Campus must engage in housing focused conversations with site staff
to be able to stay at the Nevada Cares Campus. If participants refuse to participate in housing focused conversations and/or
continually do not uphold the guidelines those participants will be asked to leave the Nevada Cares Campus. Violence will not
be tolerated and committing an act of violence upon another Nevada Cares Campus participant will result in expulsion from
the Nevada Cares Campus and reporting to law enforcement as appropriate. Nevada Cares Campus participants do not have a
property interest in the bed/space they occupy or in accommodations at the Nevada Cares Campus. Any belongings left at the
Nevada Cares Campus by a Participant will be disposed of after 7 days.
Grievance: Program staff shall allow any consumer, family member of a consumer, service provider, or community agency to
freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal or unreasonable
interruption of care, treatment, and services. Anyone involved with the Nevada Cares Campus or involved with a Nevada
Cares Campus resident who is concerned about that resident’s safety, wellbeing, quality of care or civil rights has a right to file
a complaint.

Participant Signature: _____________________________________________________ Date: _____________

Printed Name of Participant: _______________________________________________

Witness Signature: _______________________________________________________ Date: _____________

Printed Name of Witness: _________________________________________________

Updated: 9/12/22
 Consent to Disclose Confidential Client Information

Information to be released for:

Client Name, Date of Birth

Released by: Washoe County Housing and Homeless Services, 170 S. Virginia Street, Ste 201, Reno, NV 89501
Name of Agency and Staff Member (if applicable)

Released to: _____ _____

Name of Agency and Staff Member (if applicable)
Information to be disclosed:
Demographic Information Case Plan or Summary Substance Use Disorder
Mental Health Other:___________________________________________
Specify what information may be disclosed

Method of disclosure:
Fax Email Written
Verbal

Purpose of disclosure: _____________________________________________________________

____________________________________________________________________________________________

Please note: Only the minimum amount of information that is necessary to carry out the stated purpose shall be
released.

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures
have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose
was to obtain insurance. To revoke this authorization, I must do so in writing and send it to the appropriate disclosing
party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the
recipient and is no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless
treatment is sought only to create health information for a third party or to take part in a research study) and that I may
have the right to refuse to sign this authorization.

I will receive a copy of this authorization upon request. A copy of this authorization is as valid as the original.

Expiration:
(The date, event, or condition upon which the consent will expire if not revoked before)

___________________________________________________________ __________________________
Print Name, Client Signature Date

___________________________________________________________ __________________________
Witness Name, Signature Date

Updated: 9/12/22
 Informed Consent

The Nevada Cares Campus is staffed with Mental Health Counselors who provide outreach and crisis intervention
services to any participant on campus. You have the right to refuse to engage with our Mental Health Counselors. If you
choose to speak with a Mental Health Counselor, they may share information with other Cares Campus staff on a “need
to know” basis when a crisis or emergency occurs, though they will only share the minimum amount of information
necessary to assist you. By law, Mental Health Counselors must report allegations of child abuse or neglect or vulnerable
adult abuse or neglect. Mental Health Counselors must intervene and may need to share information with outside
entities (such as medical providers or law enforcement) if they believe that a person is a danger to themselves or others
as per NRS 433A.0195.

Participant Signature: _____________________________________________________ Date: _____________

Printed Name of Participant: _______________________________________________

Witness Signature: _______________________________________________________ Date: _____________

Printed Name of Witness: _________________________________________________

Ride-A-Long Waiver and Release of all Claims and Liability

The undersigned does hereby certify that I am over 18 years of age and hereby, for myself, my heirs, executors or any
person for whom I have or may have legal authority to represent, release, and forever discharge Washoe County, its
respective officers, employees, and agents from any and all liability, claims, demands, damages, actions or causes of action
arising from, or by reason of any injury to or death to me or any person or any damage to or destruction of property
resulting from being in or about, or riding in a Washoe County vehicle, whether or not such injury, death, or damage is
caused or alleged to be caused by the negligence, active or passive, of Washoe County, its officers, agents, and/or
employees.

This Release is given in consideration of, and as a condition to Washoe County, its officers, agents, and employees
permitting the undersigned to ride in a Washoe County vehicle.

This Release includes, but is not limited to, any claim, demand, or cause of action which might be caused by any act or
failure to act of Washoe County, their officers, agents, and/or employees.

I, the undersigned, have read this Release and understand all its terms. I hereby execute it voluntarily and with full
knowledge of its significance.

THIS IS A COMPLETE RELEASE. READ IT BEFORE SIGNING.

Signature: ___________________________________________________ Date: ______________________________

Description of activity: Riding in a Washoe County Vehicle.

Updated: 9/12/22