Date
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Application Date
MM
DD
YYYY
Name
*
Email Address
*
Home Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(best contact)
Country
(###)
###
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Passport Expiration Date
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(*if your current expiration date is less than 6 months after the return date of the mission, please renew your passport)
MM
DD
YYYY
Preferred Airport
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Frequent Flyer Information
TSA Precheck information
Emergency Contact Name
*
Relationship to Emergency contact
Emergency Contact Email
Emergency Contact Phone
*
Country
(###)
###
####
Insurance Beneficiary -relationship to applicant
*
Agreements: Please check all of the following boxes to indicate your understanding & agreement.
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CONSENT AND LIABILITY RELEASE AND INDEMNIFICATION
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You have chosen to participate in this trip with Africa Fire Mission and you could be subject to personal injury. To participate in this activity, sign this form to release and indemnify Africa Fire Mission and all leaders and other organizations involved in this mission trip from liability.
In consideration of being permitted to participate in this trip and intending to be legally bound, I, for myself, my legal guardian, my personal representatives, heirs, and next of kin:
1. Hereby release, waive, discharge, and covenant not to sue AFRICA FIRE MISSION, all leaders, and organizations associated with AFRICA FIRE MISSION in this mission trip from any and all claims and/or legal liability that I, my legal guardian, my personal representatives, heirs, and next of kin may have against AFRICA FIRE MISSION in this mission trip, for any and all losses or damages and any claim or demands thereof on account of injury to my person or property, including my death, arising out of the mission trip, including any negligence of AFRICA FIRE MISSION and any leaders and organizations involved. Further, I hereby release waive, discharge, and covenant not to sue AFRICA FIRE MISSION and individuals or other organizations associated with AFRICA FIRE MISSION in the trip for any claims, including, BUT NOT LIMITED TO, sickness, injury, or death that may result from hazardous traffic, poorly constructed roads, dangers resulting from military or political problems, sickness or disease.
2. Hereby agree to indemnify and to hold harmless AFRICA FIRE MISSION and any of the individuals and other organizations associated with AFRICA FIRE MISSION in this trip from any claims or liability arising out of my participation in this trip as additional consideration.
3. Hereby authorize AFRICA FIRE MISSION and its leaders to make essential decisions on my behalf regarding medical treatment, emergency surgery, or hospitalization should such medical treatment be necessary and should all reasonable and practicable efforts fail in first contacting members of my family.
4. Hereby agree to NOT hold AFRICA FIRE MISSION, any individuals or other organizations associated with AFRICA FIRE MISSION in this trip responsible or liable for the payment or any medical bills incurred as a result of this mission trip.
5. Hereby agree that in the event that I die while on this mission trip that I, my estate, my legal guardian, my personal representatives, heirs, and next of kin, will assume complete responsibility for the total cost of shipping my body.
6. Hereby agree to read and abide by the rules, regulations, and guidelines set forth by AFRICA FIRE MISSION and to abide by all decisions made by leaders and those in authority.
7. Hereby agree that in the event that I do make a claim, I, my legal guardian, my personal representatives, heirs, and next of kin, shall pay all legal fees and costs incurred by AFRICA FIRE MISSION and all individuals and organizations associated with AFRICA FIRE MISSION in the trip to defend against such claims.
8. Hereby assume full responsibility for any risk of bodily injury, death, or property damage arising out of or related to the mission trip, including any acts of negligence or otherwise.
I HAVE READ THIS CONSENT AND LIABILITY RELEASE AND INDEMINIFICATION AGREEMENT, FULLY UNDERSTOOD ITS TERMS, UNDERSTAND THAT I MAY HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARLY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
Do you agree with the above Consent and Liability Release and Indemnification?
Yes, I agree
No
I agree that this application is complete and accurate. By submitting this I am electronically signing the agreements within the application.
*
Yes, I agree
No, I do not agree - application will not be accepted
