Acknowledgement, Consent, Agreement And Release From Liability Form printable pdf download

MEMORIAL HERMANN MEDICAL MISSIONS

ACKNOWLEDGEMENT, CONSENTS, AGREEMENT AND RELEASE FROM

LIABILITY (COLLECTIVELY, "THE RELEASE")

I, _________________________________ ("Releasor"), hereby acknowledge that I have

voluntarily applied to Memorial Hermann Medical Missions to participate in a not-for-profit

medical mission to ________________________________ as a __________________________

with ___________________________________________, the organization leading and

sponsoring the medical mission.

This trip is currently scheduled to commence on _________________________(Date).

I have reviewed all information regarding __________________________________.

I wish to participate in the trip and request that Memorial Hermann Medical Missions assist me

through a scholarship, supplies and/or pharmaceuticals.

I am aware that travel to, within, and among developing countries can often be hazardous. I am

voluntarily participating in these activities with full knowledge of the potential dangers involved.

I hereby agree to accept any and all risks of delay, injury, death, and all other hazards of the

mission. In the event Memorial Hermann Healthcare System and its Memorial Hermann Medical

Missions provide partial or full funding for supplies and/or pharmaceuticals for medical mission

purposes, I take full responsibility for such items, including their ultimate distribution and use.

Occasionally, missions have been canceled due to various circumstances. In the event of such an

occurrence, Memorial Hermann Medical Missions and its volunteers will adhere to the following

policy:

In the unfortunate event of a cancellation, Memorial Hermann Medical Missions will not be

responsible to give the scholarship, supplies and/or pharmaceuticals or assume any liability for

any expense incurred by any participant including out-of-pocket costs and expenses, lost income,

vacation time or any other direct or indirect cost, loss, expense or damage incurred by the

participant, chapters or its affiliated organizations.

As consideration for a scholarship which helps me to participate in the trip or mission described

above and use of its facilities and resources, I hereby agree that I, my assignees, spouse, children,

successors, heirs, and legal representatives will not make a claim against or sue Memorial

Hermann Healthcare System or any of its affiliated organizations or its or their officers, directors,

employees, agents or volunteers for death or injury or damage to person(s) or property resulting

from any negligent or other acts of third parties or of any employee, agent, volunteer or contractor

of Memorial Hermann or any of its affiliates as a result of my participation in the subject trip or

any other medical mission trip. I hereby release Memorial Hermann, its affiliates and its and their

officers, directors, employees, agents, and volunteers from all actions, claims or demands that I,

my assignees, spouse, children, successors, heirs, and legal representatives now have or may

hereafter have for death or injury or damage to person(s) or property resulting from my

participation in the subject trip or any other medical mission trip. I agree to indemnify and hold

harmless Memorial Hermann Healthcare System and the others whom I release herein from and

against any claims, including legal defense or other direct or indirect costs or expenses, asserted

by my spouse or any other person.

Acknowledgement, Consent, Agreement And Release From Liability Form