EMERGENCY RELEASE
AND RIGHT OF REPRESENTATION
I, _____________________________________________, in
consideration of my participation on this mission
trip to _________________________, represent and agree that:
1. I am prepared physically, emotionally, mentally and spiritually for this trip. The scheduling, environment and other foreign country and travel conditions are not adverse to me. I will be flexible and have a servant attitude.
2. I grant to any of the Mission Trips Inc. leaders or their contracted agents the right to represent me in decisions relating to my welfare or the group welfare during the trip. I will follow the suggestions made on my behalf.
3. I understand the administrative roll that Mission Trips Inc. plays in putting together our mission trip. I also understand that the mission trip will be handled by a contracted agent of Mission Trips Inc. in country and the contracted agent of Mission Trips Inc. will be responsible for the trip and the team.
4. I hereby grant any of the Mission Trips Inc. leaders or their contracted agents my permission to authorize medical treatment and medication on my behalf. I will not hold any of the Mission Trips Inc. leaders or their contracted agents responsible for the results of such treatment, medications or decisions made on my behalf.
5. I am aware of the hazards and risks to myself and property associated with this mission trip. I have read the U.S. State Department's Travel Advisory (if any) for this country found at http://travel.state.gov/travel_warnings.html. These risks include, but are not limited to, death or injury by accident, disease, terrorist acts, weather conditions, and inadequate medical services and supplies. I accept these conditions with full awareness and I assume all risks of death, injury, illness, terrorist assaults and personal property loss or damage associated with such risks.
6. I attest and certify that I am physically fit and have no medical conditions that would prevent me from performing my assigned duties which may include long hikes, high altitude, heat, limited and infrequent meals. I am aware of the disease risks associated with foreign travel and I accept these risks.
7. I waive any and all claims for damages against Mission
Trips Inc., Mission Trips Inc. leaders or their contracted agents, arising from
death, injury, illness, inconvenience, or in property damage or loss occurring
as a result of this mission trip for any reason including but not limited to
any negligent act or acts of Mission Trips Inc., Mission Trips Inc. leaders or
their contracted agents which may in any way cause death, injury, illness,
inconvenience or property damage or loss to me.
I have read this release in its entirety, understand its contents and
agree to them of my own free will.
8. Governing Law/Venue: In accepting service from us then this agreement
shall be governed only by the laws of the State of
Signature____________________________________________________Date______________________
Spouse/Parent
signature________________________________________Date ______________________
STATE OF
__________________________
COUNTY OF _____________________________
On this _________day of _____________, 20____, before me, a Notary Public in and for said state, personally appeared known to me to be the person who executed the within agreement and acknowledged to me that he/she executed the same for the purposed therein stated.
Notary Public____________________________________ My commission expires___________________
Please return to:
Mission Trips Inc.
1765 E 9 mile Rd. Ste. 1 #300
Pensacola, Fl. 32514