I certify and acknowledge that I have selected a gift from Pacific Medical, Inc. through the PacMedHeartWarriors.com website.  I understand and acknowledge that I am not obligated or required to select any of the gifts offered.   I understand that any cash or cash equivalent gift (including vacation or cash amounts to be spent on vacations) are taxable by the IRS and must be reported on my Form W-2 for the year in which the benefit is received.

Furthermore, I understand that any travel/vacation related gift must be utilized (paid for) within 12 months of Employee’s anniversary date AND Employee MUST be an active employee of Pacific Medical, Inc. or Top Shelf Manufacturing, LLC to be eligible to receive/utilize any travel-related gifts.

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I fully release, indemnify and forever discharge Pacific Medical, Inc., it’s affiliates and respective employees, officers, directors, agents, or representatives from and waive all recourses, loss or damages including any consequential loss or damage, actions, causes of action, suits, debts, dues, accounts, covenants, contracts, claims and demands whatsoever, including without limitation, any claim based on the loss of ability to earn income, claims for injury, death, illness, or delay which I, my heirs, executors, administrators or personal representative now have or hereafter can, shall or may for or by reason of in any way howsoever arising out of my selection or receipt of the selected gift including any claims arising out of the subsequent use of the gift whether such use is by me or by anyone else acting with or without my knowledge and/or consent. 

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I voluntarily accept that legal risk, thereby expressly giving up any right of action, and accept any risk arising from use of the gift, prize or award and waive all liability whether such liability arises in contract, by reason of negligence, or by reason of breach of duty raised by statute, or in any other manner whatsoever.

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By signing below I certify that I have read and fully understand the above form and its terms and conditions.

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