RELATIVE'S AFFIDAVIT
CRYOCARE FOUNDATION
1013 Centre Road
Suite 301
Wilmington, Delaware 19805-1297
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1) I, __________________________________________________, residing at
(Address)_______________________________________________________________
(City, State, ZIP)______________________________________________________
state that I am _____ years of age and that I am the (relationship)
________________ of _________________________________
(who is a member of CryoCare Foundation and is referred
to below as "The Member").
2) From my own knowledge of the wishes of The Member, I
know that it has been and now is his/her intention and
desire, upon legal death, to have his/her human remains
cryogenically preserved (cryopreserved) by CryoCare in the
hope of possible restoration to life and health at some time
in the future, and for the purpose of the general advancement
of scientific knowledge.
3) I also know that in order to implement this decision,
The Member has arranged to donate his/her human remains
(under the provisions of the laws governing anatomical
donations) and appropriate funds (as determined by The
Member's contract with CryoCare) to CryoCare Foundation
(CryoCare), a Delaware not-for-profit corporation having its
principal office and place of business at CryoCare Foundation,
1013 Centre Road, Suite 301, Wilmington, Delaware 19805-1297.
I am also aware that The Member has specified cryopreservation
in his/her will as the method of disposition of his/her human
remains (pursuant to Section 7100 of the California Health and
Safety Code). I am aware that if state statutes or judicial
rulings make this arrangement legally impossible under the laws
governing anatomical donations, The Member still wishes this
procedure to be carried out by whatever legal means may be available.
4) I agree to abide by this decision of The Member and,
in order to facilitate the implementation of this decision, I
hereby grant over to CryoCare, without reservation, any and
all interests and rights I may have pertaining to the human
remains of The Member following his/her legal death. I
understand that this consent does not imply or require that I
personally subscribe to the concept of human
cryopreservation.
5) I further agree to sign any and all forms which
CryoCare may later require of me pertaining to this transfer
of interests and rights in The Member's human remains,
whether this transfer is carried out under the laws governing
anatomical donations or by some legal means as yet
undetermined.
6) I hereby disclaim and renounce any interest I may
have (subject to the laws of inheritance of the state in
which The Member resides) in any and all monies and
properties which The Member has designated or may designate
to be applied to the purpose of effecting or continuing the
cryopreservation of his/her human remains.
7) I agree to take all actions reasonably necessary to
permit, and to forego all actions which might interfere with,
the cryopreservation of The Member.
8) I agree to immediately notify CryoCare by the fastest
means available when I become aware that The Member is
afflicted with any life-threatening illness or injury and/or
upon the death of The Member.
9) I agree to cooperate in all ways with CryoCare in
assisting its personnel to gain access to The Member, to The
Member's medical records, and to The Member's physician while
The Member is being treated in a medical facility, including
the Intensive Care Unit and other areas normally restricted
to relatives only.
10) I agree to make efforts to persuade the relevant
medical authorities to release The Member's body to CryoCare
immediately after The Member's legal death. I further agree
to make such efforts, if possible, in advance of The Member's
death.
11) I agree to make any other such efforts as CryoCare
may reasonably require to aid in The Member's
cryopreservation.
12) I understand that either my failure to perform the
agreed duties, or certain other conditions may make it
impossible or impractical for CryoCare to perform the
cryopreservation of The Member and that such inability to
perform shall relieve CryoCare of its duty to cryopreserve
The Member while not necessarily disqualifying CryoCare from
the funds designated to it.
13) I understand and accept that the procedure of human
cryopreservation is experimental, unperfected and not
consistent with contemporary medical or mortuary practices.
I have read the Cryopreservation Agreement and understand
that CryoCare cannot guarantee the success or quality of any
of its procedures, current or yet to be developed, for
cryopreservation, long-term care, or possible restoration to
life and health at some time in the future. There is no
guarantee that this procedure will ever be attempted on The
Member or if attempted will be continued or successful. I
understand and accept that CryoCare warrants only that all
procedures and decisions connected with cryopreservation,
long-term care, and restoration will be made with its best
efforts and good faith judgement.
14) I understand that this Agreement is reasonably
related to the State of California, and the provisions of
this Agreement (not including the laws of inheritance of the
state in which The Member resides) are to be interpreted and
enforced according to the provisions of the laws of the State
of California. I agree that any lawsuit brought concerning
interpretation or enforcement of this Agreement or concerning
my actions or the actions of CryoCare regarding the human
remains of The Member shall be brought in a state or federal
court in Los Angeles, California.
15) I therefore agree not to make demand or claim on,
and not to prosecute or cause to be prosecuted, CryoCare, its
directors, officers, members employees, agents, and any
companies, corporations, or institutions with which CryoCare
may contract, for any action taken or committed on or against
The Member, in so far as CryoCare's decisions and actions are
made with its best good faith judgment. I hold each of these
persons and organizations free from any and all liability in
connection with Cryocare's cryopreservation program and the
cryopreservation of The Member's human remains, in so far as
CryoCare has used its best good faith judgment.
16) Questions to be answered by the Relative:
(a) It is important to the credibility of CryoCare and
of the concept of human cryopreservation in general that the
public be made aware when persons are cryopreserved. The
Member has indicated in the Cryopreservation Agreement
whether or not s/he has given permission for his/her name to
be used publicly in releases concerning his/her
cryopreservation. The Member should show you this and
discuss this decision with you.
CryoCare recognizes that because of personal grief, a
wish to avoid publicity, or an objection to the principles or
philosophy of human cryopreservation, many relatives will not
wish to become involved in any public discussion of the death
and cryopreservation of The Member. In consideration of
these feelings, CryoCare will not release the names of any
relatives to the public without their expressed permission.
However, it is the hope of CryoCare that some relatives of
The Member will agree to be interviewed by representatives of
the media or at least to release public statements after the
legal death and cryopreservation of The Member. No pressure
of any kind will be placed upon you to cooperate in this way,
and you may change your decision in this regard at any time.
Please indicate by initialing below the extent to which
you are willing to participate.
____ I permit CryoCare to release my name to qualified
media representatives.
____ I am willing to be interviewed by qualified media
representatives.
____ I may be willing to be interviewed by some specific
person after discussion with CryoCare, but I do not permit
CryoCare to release my name directly to media
representatives.
____ I may be willing to release a public statement but
do not wish to be interviewed, and I do not permit CryoCare
to release my name directly to media representatives.
____ I do not wish to participate in any way.
____ Other:_______________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
(b) CryoCare, through its service providers, offers two
essentially different methods of human cryopreservation:
Whole-Body cryopreservation, in which the patient's entire
body is cryopreserved, and Neuro-cryopreservation, in which
only the patient's head or brain are cryopreserved. The
Member should inform you which method s/he has chosen.
CryoCare further requires an "Emergency Conversion to
Neuro-cryopreservation" consent from The Member. Conversion
to Neuro-cryopreservation will take place at the sole and
absolute discretion of CryoCare in the event that in the best
good faith judgement of the CryoCare Board of Directors such
conversion is essential in order to continue the
cryopreservation of The Member.
Please initial your answers to the following:
The Member has explained the Neuro-cryopreservation option and
conversion to me. Yes _______ No _______
The Member has explained that s/he has chosen [circle one] (Whole-Body
cryopreservation) (Neuro-cryopreservation). Yes ______ No ______
I am willing to accept The Member's decision and choice.
Yes ______ No ______
My notarized signature below affirms that I have read and agree to the
statements made herein.
______________________________________
Signature of Relative
)
STATE OF _____________________________) SS.
)
COUNTY OF ____________________________)
On this the ________ day of _______________________, 19____,
before me, ________________________________________________,
the undersigned Notary Public, personally appeared
___________________________________________________________,
___ personally known to me
___ proved to me on the basis of satisfactory evidence to be
the person whose name is subscribed to the within instrument,
and acknowledged that s/he executed it.
WITNESS my hand and official seal.
____________________________________________________________
Notary's Signature
____________________________________________________________
Printed
NOTARY PUBLIC
My Commission Expires: My County of Residence is:
__________________________