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Hotline Number
323-903-7613
Service Waiver
Chaverim L.A. Service Waiver
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
First Name
Last Name
Email
Phone
Unit # providing service? - (Ask the member providing you service for their member unit number) *
Service Type requested:
Jump Start
Auto Lockout
Home Lockout
Flat Tire
Gas
Generator
Other
Auto Ownership Verification:
YES
NO, BUT I HAVE PERMISSION TO USE IT
It's a rental and I have the rental agreement
It's a rental and I DO NOT have the rental agreement
No. I do not have any way to verify it
Home Ownership Verification:
I own the property. I have ID that matches the address
I own the property. I do not have an ID that matches. I can verify a different way.
I lease the property I have ID that matches.
I lease the property I do not have ID that matches. I can verify a different way.
I have permission to enter, but I am not on any paperwork. I can verify.
No, I do not have any way to verify.
None of the options above, but I can explain when you arrive.
Terms of Use Agreement:
I, the undersigned, in consideration of Chaverim of Los Angeles providing the service requested above, hereby release, indemnify, and hold harmless Chaverim of Los Angeles and its volunteers, from all claims, demands, actions, and causes of action of every nature, including those relating to negligent acts, and including, but not limited to, all losses or expenses that may arise and relate in any way to the actions of Chaverim of Los Angeles, its employees, or agents pursuant to the companies provision of such services. I understand that such service involves the risk of damage to my vehicle or home and expressly accept the risk of any and all such damages. CHAVERIM IS NOT AFFILIATED WITH HATZOLAH. Your signature below indicates that Chaverim of Los Angeles and its employee's are released from any liability resulting from attempting to unlock your vehicle or home, or attempt any service on your vehicle. Your signature affixed to this form is testimony that you have read and understand this statement and have no questions.
Signature
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