PROJECT HEALTH FOR LEON PARTICIPANT APPLICATION
Participant’s name (As it appears on your Passport):
Gender (Used in making hotel room assignments):
Professional License(s) (and next renewal date):
Emergency Contact’s name:
Contact’s relationship to participant:
Mail to: Project Health for Leon
PO Box 9189
Asheville, NC 28815-0189
(PLEASE COMPLETE THE FOLLOWING WAIVER )
LIABILITY WAIVER, RELEASE, AND ACKNOWLEDGMENT OF RISKS
In consideration of being permitted to participate as a volunteer in connection with the medical relief efforts and other charitable activities sponsored by Project Health for Leon, a non-profit charitable organization (“PHL”), including, without limitation participating in the relief trip to Nicaragua in the city of Leon and other towns, taking place in January 2018 and thereafter, and all activities ancillary thereto (collectively the “Volunteer Activities”), I, the undersigned volunteer, on behalf of myself, my heirs, legal representatives, estate, successors and assigns, hereby agree as follows:
- Acknowledgement of Risks. I voluntarily assume all known or unknown risks of participating in any Volunteer Activities sponsored by or involving PHL. I am aware that the anticipated Volunteer Activities include travel to a foreign country to provide relief, support, and health related services to underprivileged individuals and families in impoverished areas of Nicaragua. I acknowledge that there are a number of risks involved with participation in these Volunteer Activities, including, but not limited to risk of physical or mental injury, death, or damage to myself arising out of, or as the result of weather, lodging, travel delays, consumption of improperly prepared food or unsanitary water, exposure to disease, and other risks generally associated with travel to undeveloped regions of the world and exposure to those with illness and other medical conditions. The undersigned acknowledges and agrees that this list is not complete or exhaustive, and that other risks known or unknown may also result in injury, death, illness, disease, and damage to me or my property. My participation in any activity involving PHL is purely voluntary. I elect to participate in spite of the risks. I understand these risks and voluntarily assume all risks associated with these activities.
- Release, Indemnification, and Covenant Not To Sue. I hereby voluntarily release, forever discharge, and covenant not to sue PHL, and officers, directors, and employees, and any individual or corporate sponsor of PHL, and any individual or corporate contributor to PHL, and the officers, directors, and employees of such corporate sponsor or contributor (collectively the “Released Parties”) based upon any cause of action, claim, or demand of any nature whatsoever which relate to or arise out of my participation in any Volunteer Activity, or any other activity involving PHL or conducted by PHL. I also agree to indemnify, defend, and hold harmless the Released Parties from any and all causes of action, claims, demands, losses or costs (including attorney’s fees) of any nature made by any person or entity acting on my behalf which relate to or arise out of my participation in the Volunteer Activities, or any other activity in which I participate involving PHL or which is sponsored or promoted by PHL.
- Insurance, Financial responsibility. I hereby certify that I have adequate insurance to cover any injury or damage I may cause or suffer, while participating in these Volunteer Activities or that I will bear the costs of such injury or damage myself.
- General. PHL shall have the right to restrict or deny my participation in any activity at any time and for any reason in the discretion of PHL. This release shall remain in full force and effect until revoked in writing by the undersigned participant or his legal guardian at which time the participant shall cease participation in any further activity involving PHL.
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I UNDERSTAND THAT I HAVE GIVEN UP CERTAIN LEGAL RIGHTS AND THAT THIS IS A BINDING LEGAL DOCUMENT.
Print Participant’s Name Participant’s Signature Date