Name (the name you perfer to be called) *

First Name

Last Name

Cell Phone # *

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Release of Liability and Consent to Treatment *

Whereas, I plan to participate in EMCI Mission ministry and related activities sponsored by churches and EMCI. I recognize that the participation in such activities may be hazardous and dangerous. Now therefore, in consideration of the privilege to participate extended to me by the churches and EMCI, through its officers, agents, servants, and employees, I do hereby, for myself, my heirs, executor and/or administrator, remise, release and discharge the churches and all their officers, employees, contracted workers, volunteer assistants & agents, servants, acting officially or otherwise; from any and all actions, causes of action, claims and demands for, upon, or by reason of injuries, illnesses, damages or loss or any nature, or death which may occur from any cause including but not limited to any accident while participating individually or with others in said events. I also understand by participating in the aforementioned mission trip may expose me to risks and dangers including but not limited to risks from traveling to/from a venue, overnight stays, safety hazards from the activities undertaken, theft/robbery/kidnapping or other crimes, toxic and contaminated air or water, diseases, airborne viruses and bacteria, sickness, structural unsoundness, unsafe and/or hazardous driving conditions, possible encounters with violent persons or person groups, and even death. I am aware of these risks and dangers to life and limb as an unavoidable part of my voluntary participation in the program. I agree to indemnify and hold churches harmless from any and all actions, claims, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, brought as a result of my involvement in the program (aforementioned mission ministry) and to reimburse them for any such expenses incurred. I hereby also authorize the leadership of the said mission team, acting as the team member’s agent, to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care of service, which is deemed advisable; and is rendered under the general or specific supervision of any licensed physician, surgeon, or the medical staff of a licensed hospital, wherever such diagnosis or treatment is rendered at the office of said physician/said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being rendered, but is given to provide authority on the part of the Agent to give specific consent to any or all such diagnosis, treatment, or hospital care which the above mentioned physician, in the exercise of his/her best judgment, may deem advisable. I hereby releases the said leadership any liability of the aforementioned decision. I hereby also authorize any hospital which has provided treatment to the team member to surrender physical custody of the team member to the Agent upon completion of treatment. These authorizations shall remain effective through the below period unless sooner revoked in writing and delivered to the Agent. By signing below, I declare that I have read, understood, and agreed to this release.

I agree to the liability and consent to treatment

Name on passport or green card (for mission trip insurance) *

First Name

Last Name

Date of birth (for mission trip insruance) *

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DD

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Passport Expiration Date (for mission trip insruance) *

A general rule is that a US passport must be valid for at least six months beyond the date of departure from the United States.

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DD

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