Honduras - San Pedro Sula Medical Mission Trip 2026

Background Check Authorization Form

I have never been convicted of a felony I have never been charged with sexual harassment.

Authorization: By signing below, you authorize: (a) Texas DPS to request information about you from any public or private information source; (b) anyone to provide information about you to DPS;

(c)DPS to provide us Austin Smiles – The Austin Plastic Surgery Foundation one or more reports based on that information; and (d) us to share those reports with others for legitimate business purposes related to your volunteerism. DPS may investigate your education, work history, professional licenses, and credentials, references, address history, social security number validity, right to work, criminal record, lawsuits, driving record, credit history, and any other information with public or private information sources. You acknowledge that a fax, image, or copy of this authorization is as valid as the original. You make this authorization to be valid for as long as you are an applicant or volunteer with us.

I, permit Austin Smiles, The Austin Plastic Surgery Foundation, to conduct a background check as a requirement for participating as a volunteer on a medical mission trip.

RELEASE FORM & AGREEMENT

I, hereby acknowledge that I am a volunteer for Austin Smiles, The Austin Plastic Surgery Foundation. I further acknowledge that I am not an employee or agent of Austin Smiles. I expressly recognize that I am an independent contractor and have no right to receive employee benefits, including but not limited to insurance coverage of any kind, or compensation, including workmen’s compensation, from Austin Smiles.

I have been made aware that there are potential risks and dangers involved in traveling and working in Latin America and hereby expressly agree to assume the risk of any such risks and dangers as they may arise. I fully acknowledge that I am responsible for obtaining medical insurance coverage, if I so desire, and that no insurance coverage of any kind, including but not limited to, health, medical malpractice or professional indemnity insurance, is or will be provided to me by Austin Smiles in connection with my traveling and working in Latin America as a volunteer for Austin Smiles/ Austin Plastic Surgery Foundation.

I agree to accept full responsibility for all medical expenses, personal injury damages, property damages and other damages and expenses, including but not limited to those resulting, in whole or in part, from the negligent acts of Austin Smiles which have been or may be committed and which may affect my safety or well being.

For the consideration expressed below, I hereby release and forever discharge Austin Smiles, its officers, directors, agents, servants, employees, and all other persons, firms, and corporations, whether named herein or not, of and from any and all manner of action or actions and causes of action, controversies, claims, demands, obligations, liabilities, suits, damages of every kind and character whatsoever, and debts, whether known or unknown, and howsoever, whensoever, and by whomsoever caused, solely, jointly, or otherwise, including without limitation for personal injuries and property damage, if any, in any manner and in any capacity claimed, owned, held, or possessed by me, directly or indirectly, arising out of, as a result of, resulting from, or attributable to, my traveling and working as a volunteer in Latin America.

The undersigned further agrees to indemnify, save and hold harmless any person, firm, organization or corporation hereby released, its officers, agents, directors, servants, employees, and those in privity with them and all other persons, firms, organizations and corporations, whether named herein or not, of and from any and all damages and expenses that any of them may incur or become liable for as a result of any claim, demand of cause of action arising out of or resulting from the matters which could have been or may be asserted by the undersigned as a result of participating in the Austin Smiles Medical Mission to Latin America.

The undersigned expressly agrees, understands, and declares under oath that the sole consideration for this release is the opportunity for me to participate in Austin Smiles’ medical trip to Latin America and that such consideration is contractual and not a mere recital; that all agreements and understandings between the undersigned and any person, firm, organization or corporation hereby released are embodied and expresses herein, that no representation or statement made by any person, firm, organization or corporation hereby released are embodied and expressed herein, that no representation or statement made by any person, firm, organization or corporation hereby released, or by any attorney or other representatives acting on my behalf of any of them, has influenced or induced the execution of this release.

RELEASE FORM AND AGREEMENT CONT.

I give The Austin Plastic Surgery Foundation, Inc., a Texas nonprofit corporation, DBA Austin Smiles, the right to interview and/or to take photographs, audio or audio-visual recordings of me/my child to be used in promotional, educational or fundraising materials including, but not limited to videotapes, pamphlets and brochures. I understand my/my child’s name may be used in connection with these materials. By signing this media release, I intend to legally bind myself, my children, my heirs, executors and administrators. Austin Smiles shall have the right to use photographs or other images of me/my child in promotion, educational or fund-raising materials. I acknowledge that Austin Smiles shall have all rights of copyright in and to such photographs and videotapes and may use such copyright fully. I also hereby release Austin Smiles and its officers, agents and employees from all liability connected with the taking and use of these materials as is authorized by Austin Smiles. In addition, I waive all rights, interest or claims for payment in connection with any exhibition or release of these materials.

This consent is voluntary, and I give it in the interest of public information, education, the furtherance of the goals of these institutions, or other lawful purposes. I acknowledge that I have legal authority to sign this form on behalf of myself or the minor whose name is mentioned above.