Request for exposing an employee of EXISTech Corporation to possibly harmful electromagnetic, X-ray radiation, or other form of radiation

This is an agreement (hereafter referred to as Agreement) pertaining to the
exposure of an employee of EXISTech Corporation to
electromagnetic, X-ray radiation, or any other forms of radiation
that may be harmful to the employee, or to certain of the apparatus that
employees of EXISTech Corporation are required to wear to protect their
personal safety or to carry out their duties and responsibilities
to EXISTech Corporation.

Such apparatus may include but not necessarily be limited to visual memory
prosthetic, or other body--worn processor (hereafter referred to as Prosthesis),
possibly including a physiological monitor, which may include direct connection
to the body of a user, wearer, patient, or subject of experimental apparatus
(hereafter referred to as Subject).

I request to expose Subject to a level of radiation of type _________________
(describe nature of radiation; if X-rays enter energy in mega electron volts,
if electromagnetic radiation such as found at department store exit sensors,
enter frequency and wave type ______________, not to exceed ____________
(enter amount).

I understand that Prosthesis is not a mass--produced product tested for
withstanding X--rays, or electromagnetic radiation, or other forms of
radiation, and therefore I agree to assume responsibility for possible
adverse effects of my requirement of exposing Subject to said radiation,
whether said adverse effects, real or perceived, result directly from
said radiation, or from the malfunction of said Prosthesis triggered by
exposure from said radiation.

I agree to assume responsibility for any damage caused to Prosthesis
as a result of my exposure requirement.