Hold Harmless, Waiver of Liability, and Emergency Medical Care Authorization

Marion Medical Mission is sponsoring the Journey to Africa (hereinafter referred to as the "Program").  I, _________________________ (participant name), of ____________________________________________ (address), in consideration of the opportunity to participate in the Program, and in consideration of other obligations incurred, hereby agree as follows:

1.  I fully understand that I may be traveling or staying in areas of the world that may have unstable political, economic, and security situations where acts of war, potential danger from lack of control over local population, terrorism, or violence could occur at any time.

2.   I fully understand that I may encounter difficult climates and living conditions; that risks are present concerning means of travel, food, water, diseases, pests, and poor sanitation and other health-related situations. Medical or emergency medical treatment may be inadequate or not available.

3.  I accept and assume all responsibility for my personal actions and any and all risks of property damage or personal injury that occur during or result from my participation, including potential injury while working.

4.  With the above in mind, I fully understand and agree that Marion Medical Mission, all of its entities, their staff members, successors, assigns, officers, agents, representatives, board members, and entities (hereinafter referred to as "MMM") shall not be responsible or liable in any way for any accident, loss, death, injury, or damage to myself or my property in connection with the Program, or any portion of the Program, even if said injury or action is due to the alleged negligence of MMM. Further, I do hereby agree to indemnify and hold costs and expenses (including, without limitation, reasonable attorney's fees) of whatsoever kind in connection with the Program or any portion of the Program. Further, I make this agreement on behalf of my heirs, agents, fiduciaries, successors, and assigns. I waive, knowingly and voluntarily, each and every claim or right of action I have now or may have in the future against MMM related to the Program, even if any such claim or right of action is caused by MMM's alleged negligence.

5.   I hereby state that I am in good health and have all medications necessary to treat any allergic or chronic conditions, and I am able to administer such mediations without assistance.  If at any time during the Program I need emergency medical care and am not able to give consent because of my physical or mental condition, I authorize emergency medical care decisions to be made on my behalf, and I specifically release MMM, in making those emergency medical care decisions, from any and all liability associated with said decisions, even if injury or death is the result of MMM’s alleged negligence.

6.  This document does not release MMM from gross negligence.

7.  I HAVE READ CAREFULLY, AGREE TO, AND INTEND TO BE LEGALLY BOUND BY ALL TERMS OF THIS HOLD HARMLESS, WAIVER OF LIABILITY, AND EMERGENCY MEDICAL CARE AUTHORIZATION.

Signature: ______________________________________________________________________________

Witness: ________________________________________________________________________________

Printed Name: ___________________________________________________________________________

 

Witness:_________________________________________________________________________________

WITNESS, my hand and notarial seal this         day of             , 2008.

Notary Public: