Cryopreservation Agreement - Attachment 1.
DECISIONS CONCERNING THE CLIENT'S CRYOPRESERVATION
CRYOCARE FOUNDATION
1013 Centre Road
Suite 301
Wilmington, Delaware 19805-1297
NOTE: CRYOCARE WILL DO ITS BEST TO FOLLOW YOUR WISHES; BUT WE
CANNOT GUARANTEE THAT THIS WILL BE DONE.
<<< When signing up with CryoCare, please use the hardcopy paperwork >>>
<<< provided by CryoCare rather than your own printout of this file. >>>
1. SELECTION OF SERVICE PROVIDERS
From the list in Schedule A:, select the
service providers you desire and initial your selection:
Standby, Transport, Stabilization, Cryoprotective Perfusion and cooling
to -79C:
_________________________________________________ _________
Long-Term Cryogenic Care:
_________________________________________________ _________
2. METHOD OF CRYOPRESERVATION
Both the Cryoprotective Perfusion provider and the Long-term Cryogenic
Care provider chosen above must support the Client's desired method of
cryopreservation. If a choice of method is possible, the Client must
select that method in this section, otherwise skip to section 3. The
Client should read the document, CONSENT FOR CRYOPRESERVATION before
making this decision.
Select the option you wish to be used for your cryopreservation by
initialing the appropriate space below:
Whole Body Cryopreservation _______ Neuro-cryopreservation _______
3. DISPOSAL OF NON-CRYOPRESERVED PORTION OF HUMAN REMAINS
A Neuro-cryopreservation Client or a Whole Body Cryopreservation
Client converted to Neuro-cryopreservation will have only his/her head
and/or brain cryopreserved. The Client may make arrangements through
CryoCare for cremation of the non-cryopreserved portion of his/her human
remains; or s/he may arrange for his/her next-of-kin or personal
representative to take possession of the non-cryopreserved portion of
his/her human remains. If the next-of-kin or personal representative
will be taking possession, s/he must be responsible for all expenses
involved in transfer and disposal of the non-cryopreserved portion of
the Client's human remains. If CryoCare is to be responsible for
cremation of the non-cryopreserved portion of the Client's human
remains, the fee for this service shall be paid from the Client's
Cryopreservation Funding. Unless the Client provides CryoCare with a
separate instrument by which the next-of-kin or personal representative
agree to accept possession of the non-cryopreserved portion of the
Client's human remains, and to pay all related expenses involved in
transfer and disposal of his/her human remains, CryoCare will cremate
the non-cryopreserved portion of the Client's human remains.
(NOTE: This authorization must be given by both Neuro-cryopreservation
and Whole Body Cryopreservation Clients.)
Select the option you wish by initialing the appropriate space
below:
______ I wish CryoCare to have the non-cryopreserved portion of my
human remains cremated and I authorize and direct CryoCare or its agent
to carry out this action.
______ I wish my next-of-kin to receive possession of the
non-cryopreserved portion of my human remains. I attach a separate
instrument by which my next-of-kin agree to accept possession and to pay
all related expenses. If I am unable to provide CryoCare with this
instrument or if my next-of-kin do not take possession of the
non-cryopreserved portion of my human remains within a reasonable period
of time, I authorize and direct CryoCare or its agent to have the
non-cryopreserved portion of my human remains cremated.
4. CRITERIA FOR CRYOPRESERVATION.
You might experience legal death under circumstances which would
cause considerable damage to your human remains. Under what conditions
would you want your human remains to be cryopreserved?
Select the option you wish by initialing the appropriate space
below:
______ I wish CryoCare to cryopreserve any biological remains
whatsoever that they may be able to recover, regardless of the severity
of the damage to my human remains from fire, decomposition, autopsy,
embalming, or other causes. If I have chosen the Neuro-cryopreservation
option I understand that cryopreservation will be limited to such
remains of my central nervous system or other recoverable tissues which
do not exceed a volume of 3000 cubic centimeters.
______ I wish CryoCare to cryopreserve any remains of my brain
whatsoever that they may be able to recover, regardless of the severity
of the damage to my brain from fire, decomposition, autopsy, embalming,
or other causes.
______ I wish to specify the following conditions under which my
human remains should not be cryopreserved: (Use additional sheets if
necessary.)
_______________________________________________________
_______________________________________________________
5. CRYOPRESERVATION NOT POSSIBLE.
You might experience legal death under circumstances that make it
impossible to place you into cryopreservation. These circumstances
might include legal or medical barriers or the inability of CryoCare to
locate or recover your human remains. In that event, CryoCare would
take from your Cryopreservation Funding the amount necessary to pay for
expenses incurred in an unsuccessful attempt to locate or recover your
human remains. Under these circumstances, or if the conditions stated
in Item 4 above are not met, or if for reasons discussed in the
Contingencies section of the Cryopreservation Agreement, the
cryopreservation or indefinite crogenic care of your human remains is
not possible, what do you wish done with the balance of your
Cryopreservation Funding?
Select the option you wish by initialing the appropriate space
below:
a) ______ I wish CryoCare to retain the funds provided for my
cryopreservation and apply them to other cryopreservations, previous or
subsequent.
b) ______ I wish CryoCare to retain the funds provided for my
cryopreservation and apply them to other research related to cryobiology
and life extension.
c) ______ I wish CryoCare to pay the funds to:
_______________________________________________________
_______________________________________________________
In the event that the above person or organization has predeceased
me, cannot be located, or no longer exists, I wish CryoCare to pay the
funds to:
_______________________________________________________
_______________________________________________________
d) ______ OTHER. I have attached a separate sheet detailing my
wishes in this regard.
In the event that choice c) or d) are not alive or cannot be
located, or found existing, CryoCare shall make a reasonable effort to
search out other natural heirs. The costs of this search will be paid
for out of the funds.
e) ______ If no heirs can be found, CryoCare shall apply the money
as described by _____ (a or b) above.
f) ______ If no heirs can be found, CryoCare shall dispose of the
money as prescribed by law.
6. PUBLIC DISCLOSURE.
It is the hope of CryoCare that the Client will allow us to release
his/her name and appropriate biographical information before, during and
after his/her human remains are cryopreserved. CryoCare will not
release the names of relatives unless those relatives have given their
permission in a signed Relative's Affidavit.
Please initial your choice from the following:
_______ I give CryoCare permission to release my name and appropriate
biographical details in publicity or promotional materials while I am a
living Client.
_______ I do not give CryoCare permission to release my name and
appropriate biographical details in publicity or promotional materials
while I am a living Client.
_______ I give CryoCare permission to release my name and appropriate
biographical details in publicity or promotional materials during and
after the cryopreservation of my human remains. I have discussed this
arrangement with my family.
_______ I do not give CryoCare permission to release my name and
appropriate biographical details in publicity or promotional materials
during and after the cryopreservation of my human remains.
7. DESIGNATION OF PATIENT ADVOCATE(S)
I designate the following individual(s) or organization as my
Patient Advocate:
1.
Name, Phone number ____________________________________________
Address ____________________________________________
City,State,Zip ____________________________________________
2.
Name, Phone Number ____________________________________________
Address ____________________________________________
City,State,Zip ____________________________________________
3.
Name, Phone Number ____________________________________________
Address ____________________________________________
City,State,Zip ____________________________________________
8. REQUIRED CRYOPRESERVATION FUNDING MINIMUMS.
Before approval of the Cryopreservation Agreement, CryoCare
requires the Client to guarantee a certain level of funding (the amount
depends on the Client's choice of service providers and cryopreservation
method) which will be paid to CryoCare upon the legal death of the
Client. Enter below the current minimum funding required as per
Schedule A for each of the service providers you have chosen in Section
1 of this Attachment and for the method of cryopreservation chosen in
Section 2 of this Attachment.
Service and Provider Funding Amount Required
Cryopreservation Administration: CryoCare Foundation $1,000
Long-term Care Administration: CryoCare Foundation $2,500
Trust Funds Administration: Patient Care Trust $2,000
Standby, Transport, Stabilization,
Cryoprotective Perfusion and cooling to -79C:
_________________________________________________ _________
Ecapsulation & Cooldown:
_________________________________________________ _________
Long-Term Cryogenic Care:
_________________________________________________ _________
Total Minimum Required:
CryoCare may raise these minimum required amounts once yearly by
publishing a new Schedule A to the Cryopreservation Agreement before
October 31. The Client has until December 31 of the same year to accept
the new schedule and make provision for any increase in minimum
Cryopreservation Funding necessary.
9. ADMINISTRATION AND READINESS FEES
To defray the administrative costs of the permanent enrollment of
the Client in CryoCare's cryopreservation program, the Client must pay
the yearly fee indicated below. In addition, for each of the service
providers chosen by the Client in Section 1 of this Attachment which
charge a Readiness Fee, the Client must enter the fee below. These fees
may be paid annually or quarterly. CryoCare may increase any of these
fees by republishing Schedule A as described above.
Service and Provider Readiness Fee
CryoCare Foundation $350.00
Standby, Transport, Stabilization,
Cryoprotective Perfusion and cooling to -79C:
_________________________________________________ _________
Ecapsulation, cooling to -196C
and Long-Term Cryogenic Care:
_________________________________________________ _________
Total Annual Readiness Fees
You may choose to pay the total fee above annually or quarterly.
In order to defray the costs, quarterly payments are each 27.5% of the
annual payment.
Do you wish to pay annually or quarterly?
_______ Quarterly _______ Annually
10. INITIAL SIGNUP FEE
To defray the cost of providing the Client with the necessary
information and guidance to allow him/her to make an informed choice
concerning cryopreservation, and to pay for the costs involved in
producing this signup documentation and seeing the Client through the
signup process, CryoCare makes a one-time only charge of $150.00 upon
the enrollment of a Client into its cryopreservation program.
11. CHOICES FOR FUNDING OVER THE MINIMUM
This section allows those Client who provide more than the mimimum
funding required by CryoCare, to make choices concerning the allocation
of extra funding. Please specify the percentage of extra funding to be
allocated to:
The Client's Patient Care Trust Account ____% of extra principal
The CryoCare Foundation Legal Defense Fund ____% of extra principal
____% of income from extra principal
Long-term Cryogenic Care Emergency Fund ____% of extra principal
____% of income from extra principal
Research on Revival and Restoration ____% of extra principal
____% of income from extra principal
Other arrangment
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
11. CLIENT'S GUARANTEE.
The Client hereby guarantees that the minimum amount of
Cryopreservation Funding shown in Section 8 of this Attachment has been
provided for, and that such funds will be paid to CryoCare at the time
of the legal death of the Client.
12. SIGNATURE OF CLIENT
YOUR SIGNATURE BELOW CONFIRMS YOUR ACKNOWLEDGMENT THAT:
1. You have read, understood, and consented to all of the provisions of
the Cryopreservation Agreement, including the Schedule A: Service Providers,
Required Costs and Cryopreservation Funding Minimums and any other schedules
or attachments which may be appended to that Agreement.
2. Additionally, you have read and understood and have given all
required directions and information in this Attachment 1: Decisions Concerning
the Client's Cryopreservation.
3. You are fully aware of and accept the risks and limitations explained
in these documents.
4. The proposed research procedures have been satisfactorily explained
to you by the officers, representatives, and/or other personnel of CryoCare.
_________________________ ______________________________
Signature of Client Responsible person if Client is
unable to sign or is an unemancipated
minor or otherwise incompetent.
_________________________
Date
__________________(a.m./p.m.) ______________________________
Time Relationship to Client
13. WITNESSES' SIGNATURES
Two (2) witnesses are required to sign in the presence of each
other and the Client. At the time of signing, witnesses must not be
relatives of the Client, health care providers of any kind, or officers,
directors, or agents of CryoCare.
YOUR SIGNATURE AS WITNESS CONFIRMS YOUR ACKNOWLEDGMENT THAT:
1. You have witnessed the signature of the Client on this
Attachment 1: Decisions Concerning the Client's Cryopreservation.
2. The Client has represented to you that s/he has read and
understands and agrees to the purposes and terms of the Cryopreservation
Agreement, the Schedule A: Service Providers, Required Costs and
Cryopreservation Funding Minimums and any other schedules or attachments
which may be appended to that Agreement, including specifically this
Attachment 1: Decisions Concerning the Client's Cryopreservation.
3. The Client has declared to you that cryopreservation
constitutes his/her last wish as to the disposition of his/her body and
person after legal death.
WITNESSED THIS _______ DAY OF _____________________, 19__________
TIME ______________(a.m./p.m.)
1. signature ____________________________________________
Printed ____________________________________________
Address ____________________________________________
____________________________________________
2. signature ____________________________________________
Printed ____________________________________________
Address ____________________________________________
____________________________________________
14. CRYOCARE APPROVAL
THE UNDERSIGNED ACTING BY AND FOR THE BOARD OF DIRECTORS OF THE CRYOCARE
FOUNDATION, THIS ______ DAY OF ______________, 19_________ HEREBY APPROVE THIS
Attachment 1: Decisions Concerning the Client's Cryopreservation.
_______________________
Brian Wowk, President
Seal
_______________________
Member, Board of Directors