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Secondary Individual Release

TRIP INFO
Trip Date *
Trip Date
REGISTRANT INFO
Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
RELEASE OF LIABILITY/CONSENT
• I plan to serve with Baja Bound Ministries in mission and related activities sponsored by Baja Bound Ministries. I recognize that the participation in such activities may be hazardous and dangerous. • In consideration of the privilege of participation extended to me by Baja Bound Ministries, through its officers, agents, servants and employees, I do hereby, for myself, my heirs, executor and/or administrator, remise, release and discharge Baja Bound Ministries, its officers, directors, principals, agents, servants, employees, heirs, administrators and assigns and/or representatives, from any and all claims, demands, causes of action or liabilities, specifically including claims, demands, causes of action or liabilities arising out of any negligent act by Baja Bound Ministries or its officers, directors, principals, agents or servants resulting directly or indirectly in injury, damage, loss or death, to my person or property (including property damage to any of my belongings) which may occur from any cause including, but not limited to serving individually or with others in the Baja Bound Ministries ministry or related activities sponsored by Baja Bound Ministries. • I understand that by signing this Release of Liability, I expressly and willingly agree to assume complete responsibility for any risk of injury of death that may arise from serving with the Baja Bound Ministries or related activities sponsored by Baja Bound Ministries. On behalf of my heirs, assigns and next of kin, and myself I waive all claims for damages, injury or death sustained by my property or me. If I am injured from serving with Baja Bound Ministries ministry or related activities sponsored by Baja Bound Ministries I will not hold Baja Bound Ministries, its officers, directors, principals, agents, servants, employees, heirs, administrators, assigns and/or representatives responsible even if the injuries were caused by negligence on my part or that of Baja Bound Ministries or any other party under or affiliated with Baja Bound Ministries. • I do not have any physical, medical or mental limitation, ailments or disabilities that would limit or prevent me from serve with the Baja Bound Ministries ministry, related activities sponsored by Baja Bound Ministries or that would void Release of Liability. • I HAVE READ AND FULLY AGREE TO THE TERMS OF THIS RELEASE OF LIABILITY. I UNDERSTAND AND CONFIRM THAT BY SIGNING THIS RELEASE OF LIABILITY I HAVE GIVEN UP POSSIBLE FUTURE LEGAL RIGHTS. I HAVE SIGNED THIS RELEASE OF LIABILITY FREELY, VOLUNTARILY AND UNDER NO DURESS OR INDUCEMENT.
Date *
Date
MEDICAL RELEASE FORM
Registrant Name *
Registrant Name
Doctor's Phone *
Doctor's Phone
(If none, please put N/A)
(If none, please put N/A)
(If none, please put N/A)
EMERGENCY PHONE NUMBERS (Please list 2 including name and relationship to applicant)
Name *
Name
Phone *
Phone
Name *
Name
Phone *
Phone
CONSENT FOR EMERGENCY MEDICAL TREATMENT
Please Note: It is understood that every attempt will be made to notify the volunteer’s emergency support system before treatment is given.
AUTHORIZATION In the event that I am unable to authorize treatment for myself, I hereby authorize a Baja Bound Ministries representative to procure emergency medical, hospital, or dental care in the event of injury or illness, while I am serving on the mission field in Mexico. I understand and agree that I am financially responsible for any care so procured. The undersigned volunteer grants consent to a Baja Bound Ministries staff member to give written authorization for medical treatment including x-ray examinations, medical or surgical diagnosis, and/or treatment and hospital care to be rendered under the general or special supervision and advice of a physician and surgeon licensed under the provisions of the Medicine Provisions Act: or to x-ray examinations, anesthesia, dental and/or surgical diagnosis or treatment and hospital care to be rendered to volunteer by a dentist licensed under the provisions of the Dental Practice Act.
PARENTS/LEGAL GUARDIANS (For participants under 18)
(If self, please type N/A)
(If self, please type N/A)
Date
Date
International Volunteer Insurance Coverage
Coverage is available for as little as $3.30 per person, per day and will normally cover: • Medical emergencies • Emergency extraction • Personal liability • Lost or damaged luggage • Travel disruptions such as flight cancellations • Loss of valuable items • Other unforeseen events • For more information on coverage ask your Baja Bound representation.
I would like to receive Baja Bound's monthly newsletter, to the email address I entered above, to hear about their latest trips, future aspirations, and what I've helped them accomplish.
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