I understand that I am not allowed to go on any Disaster Relief mission trip without personal medical insurance coverage and certify that I am covered.

I give my permission for the designated/approved representatives of Colorado Baptist General Convention to secure needed emergency medical attention on my behalf in case I am incapacitated.

Emergency Contacts (please list two people):

If you need more space for medications or allergies please email the list at DBelz@ColoradoBaptists.org.

Signing the hard copy of this document on deployment I will be giving my permission for the designated/approved representatives of Colorado Baptist General Convention to secure needed emergency medical attention on my behalf in case I am incapacitated.

As a volunteer member of Colorado Baptist Disaster Relief, I agree that, as my availability and ability allow, I am expected to:

1. Complete (a) a disaster relief skill checklist and, (b) provide my beneficiary's name and address.

2. Complete the required training and renew required training a minimum of every three years; take optional training which will increase my usefulness as a team member.

3. Take responsibility for my spiritual and mental preparation as a disaster relief volunteer, as well as my work skills needed at the disaster site.

4. Represent my Lord and Savior, church, fellow Christians and team as Christ would want, in my attitude, behavior, speech, dress, and work. 5. Wear official disaster relief apparel and display the SBC Disaster Relief logo only as prescribed and only while engaging in a relief event.

6. Protect my health and safety and the health and safety of victims, coworkers and all other persons while en route to and from and while at the disaster site; inform on-site team leaders of any physical limitations to be considered in my work assignments.

7. Inform the state director of my availability for a disaster response through the prescribed methods. 8. Pay my own expenses, arrange my own transportation and bring clothing, bedding, and personal items I will need at the disaster site. 9. Upon deployment, I will provide a copy of my medical insurance card and complete the health information form.

10. Upon deployment, if I am using my personal vehicle, I will provide proof of my auto/ liability insurance on that vehicle.

Please continue to the Release and Indemnity Agreement

I do hereby represent and acknowledge that I am entering upon a missionary venture with others, and that as a volunteer am paying my own expenses, including insurance, for the purpose of helping in times of disaster for the glory of God and to demonstrate my faith in Christ; that the work may at times be hazardous and somewhat arduous and will be performed by concerned volunteers and qualified professionals trained in disaster work; that vehicles transporting said volunteers will be operated by volunteers, who may or may not be professional drivers.

I recognize and acknowledge potential accidents at the disaster site, involving motor vehicles, in or about the living, sleeping, and eating areas, or during activities of the disaster relief team; am fully aware of possible injuries to members of the disaster relief team, including myself.

Therefore, I desire to protect, release, acquit, indemnify, and hold harmless from any and all claims, injuries, damages, losses, expenses or attorney fees incurred by me, my heirs, administrators, executors or assigns.

For and on behalf of myself, my heirs, administrators, executors, assigns, and all other persons, firms or corporations, I do hereby release and discharge from liability all other persons on the disaster relief team with me, those who notified, selected, or assigned me to the said team, the state disaster relief director or department, the Colorado Baptist General Convention, the Southern Baptist Convention, their employees and representatives, successors or assigns, from any claims, demands, damages, actions, causes of actions which I, the undersigned, have or may hereafter, and on account of, or any way growing out of injuries or damages both to persons or property resulting or that may hereafter result from the voluntary venture.

This waiver, release and indemnity agreement is fully understood by me and I enter the same willingly for the purposes herein above stated.

No insurance coverage is provided to volunteers by Colorado Baptist General Convention. Personal liability is the responsibility of the volunteer.

In connection with Colorado Baptist General Convention, Ponderosa Retreat & Conference Center, Colorado Baptists Disaster Relief & other entities of the Convention considering me for paid or volunteer work, I authorize Colorado Baptist General Convention, Centennial, Colorado and or its agent, Trak-1 Technologies, to obtain a consumer report, or investigative consumer report which may include information on my character, general reputation, personal characteristics, and mode of living from public record sources or through personal interviews with previous employers or associates. By execution hereof, I acknowledge that I have been advised that a report will be requested and used for the purpose of evaluating me for paid employment or volunteer service. Iauthorize, without reservation, any person or entity contacted by Colorado Baptist General Convention, Ponderosa Retreat & Conference Center, Colorado Baptists Disaster Relief & other entities of the Convention or its agent, Trak-1 Technologies to furnish the above-stated information, and I release any such person or entity from any and all liability for furnishing such information. I further release Colorado Baptist General Convention, Ponderosa Retreat & Conference Center, Colorado Baptists Disaster Relief & other entities of the Convention, its affiliated companies, their officers, employees and agents, and specifically, Trak-1 Technologies, their affiliated companies, their officers, employees and agents from any liability and responsibility arising from the preparation of said report. I understand that false or misleading statements made on this authorization, or made during the review process, will disqualify me from consideration for employment or volunteer service or result in my immediate discharge if employed.

"Date of Birth" (DOB) or "Age" will be used solely for the purpose of Identification in doing background checks and will not be considered or used for any other purpose.

In connection with the Colorado Baptist General Convention or its entities, considering you for employment (paid or volunteer), volunteer assignment, continued employment, promotion or reassignment, Colorado Baptist General Convention may obtain a consumer report on you which may include information on character, general reputation, personal characteristics, and mode of living from public record sources or personal interviews with previous employers or associates. You have the right, upon written request, to receive a written description of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act.