Waiver of Liability

Email*

example@example.com

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you 18 or older?

YesNo

If under 18, parent who is authorizing his/her travel and affirming this liability agreement.
Enter contact info of parent and relationship below:

Parent Name*

First NameLast Name

Parent Email*

example@example.com

Parent Phone*

Please enter a valid phone number.

Is this parent the emergency contact?

YesNo

If no, list the minor's emergency contact below

Emergency Contact*

First NameLast Name

Emergency Contact Email*

example@example.com

Emergency Contact Phone Number*

Please enter a valid phone number.

Age of participant*

Church Group*

Allergies to food*

YesNo

If yes please describe

Uses/Maintains an epipen*

YesNo

Today’s Date

Date

Enter Dates of Trip Below

Start Date of Trip

Date

End Date of Trip

Date

By signing below the above I release the AWAKEN DISCIPLESHIP AND TRAINING CENTER, its officers, employees and sending church (AWAKEN LAS VEGAS) from any and all liability for any acts or omissions related to the rendering of medical services to the patient in Mexico, in connection with the mission on the above dates. In the case of a minor, I his/her parent am affirming the release of all liability for my child.

I fully understand that the missions trip has risks of accident, injury or disease, which may be caused by my own actions or inactions, the actions or inactions of Awaken Discipleship and training center or others, or the conditions at the locations where the missions trip will take place. There may be other potential risks either not known to me or not readily foreseeable at this time. I fully accept and assume all such risks and all responsibility for losses or damages I may incur due to my participation in the missions trip.

I certify that I am qualified, in good health and in proper physical condition to participate in the mission.

I further hereby waive and release any and all rights and claims for loss or damage, at law or in equity, that I may have against Awaken DTC, its officers, employees, volunteers and sending church (Awaken Las Vegas) now or in the future for any and all illness, injury, loss or damage suffered by me as a result of my participation in this missions trip, even if the loss or damage is caused by the person I am releasing. This Waiver and Release is binding on my heirs, successors, assigns, personal representatives, administrators and executors.

Signature*

By signing below, I certify that I have read the contents of this document, fully understand its provisions, and freely execute this Waiver and Release. An email will be sent to be affirming this form and will also be stored (electronically) at the Awaken Discipleship and Training Center.

Signature*