Trip Waiver Form

WAYS Mission Opportunities  -  US & International

                                                                         Workdays for Adults and Youth in Service

(Please read before signing, as this constitutes the agreement as a volunteer and the understanding of your working relationship with WAYS and the Haitian Baptist Convention)

I HEREBY ASSUME ALL OF THE RISKS OF TRAVELING TO AND FROM AND WORKING IN HAITI, PARTICIPATING AND/OR VOLUNTEERING IN ACTIVITIES ASSOCIATED WITH WAYS, and the Haitian Baptist Convention including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.

I, _____________________________, acknowledge and state the following:

^{(Print Name)}

I have chosen to travel to Haiti to perform relief work including -  cleanup, construction, medical relief, food distribution, activities with youth and children.

I understand that this work entails a risk of physical injury and often involves hard physical labor, heavy lifting, and other strenuous activity; and that some activities may take place on ladders and building framing other than ground level.  I also understand that Haiti is a place of great deprivation – political unrest and disease.  I acknowledge that travelling to Haiti involves a test of a person’s physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, and weather, condition of participants, equipment, vehicular traffic, and actions of other people. These risks are inherent to my travelling to and from and working in Haiti.  The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I certify that I am physically fit, have sufficiently prepared for travel and work in Haiti. I have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my travel or work in Haiti.

I understand that I am engaging in this project at my own risk.  I understand that this is a “grass roots” activity to support individuals adversely affected by a disaster.  I assume all risk and responsibility for any damage or injury to my property or any personal injury which I may sustain while involved in this project, and related material costs and expenses.

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“WAYS”                          

The Rev. Nancy Shantia Wright-Gray

PO Box 7028, Ocean Park ME 04063                                        508.450.2001  shantiawg@gmail.com

In the arrangement of accommodations, I understand that I am solely responsible or liable for my personal effects and property.  The organizations involved in organizing this event will not provide

lock up or security for any items.  I will hold them harmless in the event of theft or for loss resulting from any source or cause.  I further understand that I am to abide by whatever rules and regulations may be in effect for the accommodations and the work sites at that time.

I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my travelling to and from and working in Haiti.

(B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE WAYS, GSMC and Good Samaritan Hospital  from any and all liabilities or claims made as a result of making arrangements to travel to and from and to live and work in Haiti, whether caused by the negligence of release or otherwise. I acknowledge that WAYS, GSMC and Good Samaritan Hospital and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific event or activity on behalf of my travel to and from and living and working in Haiti.

Signature:		Date:
Witness:

 

“WAYS”                          

The Rev. Nancy Shantia Wright-Gray

PO Box 7028, Ocean Park ME 04063                                        508.450.2001        shantiawg@gmail.com