INTERNATIONAL TRAVEL LIABILITY RELEASE FORM

I, ________________________________________ (name), understand that . . .

· Participating in a mission’s trip to _____________________________ is elective and that I could encounter health and /or safety risks as a result of that decision.

· It is my responsibility to assess all of the risks associated with traveling to _________________________ and that I am at liberty to change my mind about participating at any time before departure. I affirm that I have completed that assessment and have decided to participate in this mission trip.

· It is my responsibility to maintain a current knowledge of travel advisories, medical advisories or other risks until my departure and while I am on location (for more on this, go to www.gomissiontrip.com/missions/links.html).

· It is my responsibility to notify the team leadership if I learn of anything that would alter the risks to others or myself at any time.

· The team leaders, individuals in our group, or the staff in ______________ may not be able to intervene or rescue me if I become involved in acts of crime or violence.

· Medical care and medical facilities might not be readily available and that they probably will not meet the standards expected in the United States. To the best of my knowledge my health is good enough to undertake the trip. If I have any question about my health, I will visit my physician and discuss this trip before I go. I understand that I will be traveling to places where little to no health care will be available. In addition, I understand that I may undergo types of exertion that I am not used to.

· I have been made aware that I can purchase a comprehensive short-term, travel policy at www.gomissiontrip.com and I have declined this option.

I agree to . . .

· Act in a responsible way while in ______________ and to follow the directions of the leadership to minimize risks to myself and other members of the team.

· Release and hold harmless ______________________ (the mission) and all officers, agents and staff of the mission organizations for any and all claims and costs due to any liability, injury or damage which might occur as a result of my international experience, associated travel and living arrangement.

Because it could be in my best interests, I agree to allow the team leadership to release personal information about me to the US State Department or other agencies if they believe that it would be in my best interest.

__________________________ _____________________________

Signature of mission volunteer Printed name of mission volunteer

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Signature of witness Date