American Baptist Churches of Pennsylvania and Delaware January 30 - February 6, 2019 (Wednesday Wednesday) Haiti Mission Trip Part 1: Mission Trip Application: The total Cost is $1,175 $400 Deposit Due September 30, 2018 Second Payment of $400 Due November 30, 2018 Final Payment of $375 Due By January 1, 2019 Name: Address: City, State, Zip: _ Date of Birth: Age: Sex: Phone: Work Phone: Cell Phone: E-mail: Occupation: Construction Skills: Church Name: Association: Phone: Church Address: I Would be Willing to Lead Devotions with the Group: Yes No (Leading Devotions is Voluntary.) Why Have You Decided to Participate in This Mission Trip? Please Briefly Describe Your Spiritual Journey? How Do you Plan to Share this Experience with Family and Friends?
Part 2: Emergency Contact Information: Family Doctor: Telephone: List Any Health Issues or Special Needs Regarding Meals, Transportation, Housing, etc. List Any Allergies: List Any Food Allergies or Concerns: List All Medications: Does Your Medication Need Refrigeration? Yes No Insurance Carrier: Insurance Carrier s Telephone: Emergency Contact: Telephone: Policy #: (Make Sure Your Policy Covers You Overseas) Relationship: Email: If you have a history of seizures, heart disease, respiratory problems, diabetes, if you are recovering from recent surgery, or if you have any other chronic medical conditions, you may want to reconsider. Conditions in Haiti are difficult. There is no medical care other than what you and the other members of your team can provide. Please make a copy of the Identification Pages of your Passport (the 2 pages with your picture and passport #) and return them with this registration packet. Please Return to Haiti Mission Trip; ABCOPAD; 159 N. Bellefield Avenue; Pittsburgh, PA 15213 Phone: 1-888-687-0883 or 412-687-3940/dveselicky@abcopad.com 2
Part 3: Volunteer Request and Release: I hereby request permission to assist, as a volunteer worker, in the charitable and religious work of the American Baptist Churches of Pennsylvania and Delaware (ABCOPAD), First Baptist Church of Waynesburg and International Ministries/American Baptist Foreign Mission Society (the Society), a non-profit organization. I understand that in rendering such volunteer assistance in the work I shall under no circumstances be deemed an employee for any purpose. In consideration of the grant by ABCOPAD, First Baptist Church of Waynesburg and the Society, of the permission I hereby request, I agree that I shall perform such volunteer work at my own risk. I, for and in consideration of being permitted to participate in the mission of ABCOPAD, First Baptist Church of Waynesburg and of the Society as a volunteer, and other valuable consideration received from ABCOPAD, First Baptist Church of Waynesburg and the Society, the receipt of which I hereby acknowledge, hereby waive, release, and forever discharge ABCOPAD, First Baptist Church of Waynesburg and the Society, of and from all manner of actions, causes of action, suits, debts, covenants, contracts, agreements, promises, claims and demands whatsoever, which I have, or which my personal representative, successor, heir or assign, can or may have, against said ABCOPAD, First Baptist Church of Waynesburg and the Society, by reason of or related in any way to my participation in the mission sponsored by ABCOPAD, First Baptist Church of Waynesburg and the Society. I agree to indemnify ABCOPAD, First Baptist Church of Waynesburg and the Society from all liabilities arising in favor of third parties resulting from my conduct while serving as a volunteer on a mission, preparing for a mission, or traveling to or from the location of a mission. I also waive any right to assert any claim against ABCOPAD, First Baptist Church of Waynesburg and the Society or its agents with respect to work performed or any injury, illness or loss which I or any minor child or other person who is dependent on me may sustain in the course of, or which arises out of, such volunteer work or such accompaniment. I waive any such claim both for myself and for any such minor child or other dependent person. I understand that the Society provides travel accident insurance that provides accidental death and dismemberment benefits with a principal sum of $25,000, a medical evacuation benefit covering up to $100,000, and accident medical treatment benefits of up to $5,000 for accidental injury occurring from service by approved volunteers and persons, such as spouses, minor children or others, who accompany such volunteers. I agree to be liable for any expenses that exceed the original cost, including but not limited to early return expenses, uninsured medical expenses and emergency evacuation. I have reviewed and signed the ABCOPAD, First Baptist Church of Waynesburg and the Society s International Volunteer Health Risks and Responsibilities and the Volunteer Request and Release forms. I have read these documents thoroughly and agree to all their terms. I have had an opportunity to consult with an attorney before signing them. I support the mission of International Ministries to glorify God in all the earth by crossing cultural boundaries to make disciples of Jesus Christ. I have read, understood, and agree to abide by all the statements on this application and have provided truthful accurate information in response to the questions, to the best of my knowledge. Signature: Signature: Parent/Legal Guardian Date: Date: Please Return to ABCOPAD; 159 N. Bellefield Avenue; Pittsburgh, PA 15213 Phone: 1-888-687-0883 or 412-687-3940/dveselicky@abcopad.com 3
Part 4: Health Risks and Responsibilities: Please read the following carefully. There are risks and responsibilities you assume when you volunteer. I have discussed with my team leader/missionary/host partner/agency the health responsibilities I will have and the health care risks I may face. I understand that certain dangers that result from my travel in the pursuit of voluntary mission service are unforeseeable, such as illnesses without access to adequate medical facilities for treatment, political unrest that may result in injury, imprisonment or death. Accidents may occur with no advance notice. Hostilities may result in my being held hostage, or being stranded and not being able to return to home. I understand that this list of dangers is not comprehensive. I understand that the dangers are beyond the control of ABCOPAD, First Baptist Church of Waynesburg the Society and/or international partner and host churches, but I still want to volunteer my services. I recognize that ABCOPAD, First Baptist Church of Waynesburg and the Society s policies prohibit them from intervening on my behalf should any calamity arise. I recognize that ABCOPAD, First Baptist Church of Waynesburg and the Society will not pay any amount to remedy my situation, including the payment of ransom or bribes. I recognize most United States insurance policies do not cover me outside the United States and that I am responsible for securing medical insurance to cover my activities on the trip beyond the minimal travel insurance policy secured through the Society. I understand that traveling, living, and working abroad may present health risks through illness or accident greater than those I may encounter in the United States. I know that access to effective medical care may be difficult abroad. I assume the responsibility to familiarize myself and talk with my personal physician regarding the risks attendant upon traveling, living, and working in the areas to which I will be going. I also understand that I must take reasonable steps to minimize foreseeable risks to my health, and that of others, by taking necessary precautions before and while traveling, living and working abroad. I will adhere to the health and safety practices, policies and precautions in any mission community that I join or visit. I realize that there are health risks, which can be encountered overseas including, among others, the risk of contracting Chikungunya, Hepatitis and Acquired Immune Deficiency Syndrome (AIDS). I am aware that AIDS can be contracted through bodily fluids. I understand that in some countries, tests for the presence of AIDS antibodies are mandatory for all foreigners--before, during or at the close of their stay. I understand that a foreign government may condition entrance to, visitation in or departure from a country upon the satisfactory results of such medical tests. I will cooperate with ABCOPAD, First Baptist Church of Waynesburg and the Society and comply with any such governmental condition or requirement. I understand that various inoculations and vaccinations may be required or advisable prior to traveling to the country or countries where the mission to whom I am assigned is located. I acknowledge that it is my responsibility to determine which inoculations and vaccinations are required and I have received all such required treatments. If my spouse or any minor child or other person who is my dependent is accompanying me, I understand that I will be responsible for the health care of such person. I acknowledge that I have considered and discussed with each such person the health needs of and health risks to them and, if appropriate, to others, in accordance with the foregoing. With respect to any such person, I will comply with the requirements set out above, and I will use my best efforts to have such person comply with those requirements. Signature: Signature: Parent/Legal Guardian Date: Date: Please Return to ABCOPAD; 159 N. Bellefield Avenue; Pittsburgh, PA 15213 Phone: 1-888-687-0883 or 412-687-3940/dveselicky@abcopad.com 4
Part V: International Travel Authorization (Required if Under the Age of 21) We/I (Parent/Legal Guardian s Name) of (Address) are parents/legal guardians of (Name of Minor), a minor child, who resides with us at the address set forth above. We/I hereby authorize the minor to travel in Haiti during the dates of January 30 - February 6, 2019, with the American Baptist Churches of Pennsylvania and Delaware. Parent/Gardian Signature: Parent/Gardian Signature: Date: Date: Note: In the case of two parent families (including the situation where the parents are divorced and share legal custody) or joint legal guardians, BOTH parents or legal guardians must sign this form and have it notarized. In the case of single parent families and a single legal guardian, the sole parent/legal guardian may sign. Notary: State of Parish/County of On this day of, (year), before me personally appeared to me known to be the same person described in and who executed the within instrument, and who acknowledged the same to be the free act and deed thereof. In Testimony Whereof, I have hereunto subscribed my name and affixed my official seal on the day and year above written. Notary Public: My Commission Expires: Please Return to ABCOPAD; 159 N. Bellefield Avenue; Pittsburgh, PA 15213 Phone: 1-888-687-0883 or 412-687-3940/dveselicky@abcopad.com 5
ASSUMPTION OF RISK WAIVER AND RELEASE - ADULT - PLEASE READ CAREFULLY THIS IS A LEGAL DOCUMENT. BY SIGNING THIS DOCUMENT, THE UNDERSIGNED (THE "PARTICIPANT") IS GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. THE PARTICIPANT IS ALSO ASSUMING CERTAIN OBLIGATIONS AND GRANTING PERMISSION FOR EMERGENCY MEDICAL TREATMENT. NOTWITHSTANDING PRECAUTIONS TAKEN, ACCIDENTS OCCUR. THIS AGREEMENT MUST BE SIGNED IN ANTICIPATION OF THAT POSSIBILITY. To: HEART TO HEART CHILDREN S HOME IN HAITI SOCIETY (the "Society") In consideration of the Society sponsoring or being involved with a humanitarian trip to Haiti, particularly but not limited to the Heart to Heart Children s Home and School operated by the Society, in which the Society is permitting the Participant to be involved (the Haiti Trip ), the Participant hereby: (a) (b) (c) (d) (e) (f) (g) (h) (i) affirms that he/she is at least nineteen (19) years of age; acknowledges that Activities referred to herein means the Haiti Trip and all things related thereto, including, but not limited to: travel to, from and within Haiti; accommodations; meals; childcare activities; building activities; physical activities; humanitarian relief work; and any other activities, functions, and events undertaken or attended during the Haiti Trip; acknowledges that transportation systems, housing accommodations, health care, public safety and other facilities in Haiti may vary greatly from what is normal or expected in North America; acknowledges that some or all of the Activities may involve private and/or public transportation; understands and acknowledges that some or all of the Activities may involve risks of harm to the Participant and/or damage to the property of the Participant, and that the likelihood of the occurrence of harm to the Participant and/or damage to the property of the Participant is not determinable; understands that unintended injuries and death may possibly result as a consequence of some or all of the Activities; accepts full risk and responsibility for the death of or injury to the Participant and any damage to the property of the Participant arising from any of the Activities; waives any rights whatsoever that the Participant may have now or in the future against the Society and, as applicable, its members, directors, officers, leaders, agents, volunteers and employees as a result of the death of or injury to the Participant and/or damage to the property of the Participant arising from any of the Activities; releases, forever discharges and covenants not to sue the Society, its members, directors, officers, leaders, agents, volunteers and employees from and in relation to all liability, actions, causes of action, suits, claims and demands whatsoever that may arise from any of the Activities;
- 2 - (j) (k) (l) (m) (n) (o) agrees to indemnify and holds harmless the Society, its members, directors, officers, leaders, agents, volunteers and employees from any liability, costs, damages, expenses, actions, suits, claims, and demands whatsoever arising from any negligent, wrongful or illegal act or omission of the Participant in respect of any of the Activities; represents that he/she has obtained, or will obtain prior to the commencement of the Haiti Trip, adequate travel insurance covering the period from the commencement to the conclusion of the Haiti Trip; agrees that in the event of a medical emergency occurring during the Haiti Trip, permission is granted to the Society and the Society s leaders to authorize necessary emergency treatment for the Participant, and that all costs and expenses incurred in connection with such medical treatment will be the responsibility of the Participant; agrees and understands that this document and all permissions, consents, covenants, agreements, representations and understandings contained herein are irrevocable; agrees and understands that this document will be binding on the heirs, executors, administrators and assigns of the Participant; and agrees that if any provision hereof is invalid, illegal, or incapable of being enforced by reason of any rule of law or public policy then such provision will be severed from and will not affect any other provision contained herein, and this instrument will be read as if such invalid, illegal or unenforceable provision had never been contained herein and all other provisions hereof will, nevertheless, remain in full force and effect and no provision will be deemed to be dependent upon any other provision. The undersigned acknowledges that he/she has read this waiver, understands that legal rights are being affected, and agrees to the foregoing. DATE: Participant Signature Name (please print) Address Contact number(s)
ASSUMPTION OF RISK WAIVER AND RELEASE - MINOR/GUARDIAN - PLEASE READ CAREFULLY THIS IS A LEGAL DOCUMENT. BY SIGNING THIS DOCUMENT, THE UNDERSIGNED PARENT(S)/GUARDIAN(S) (THE PARENT(S)/GUARDIAN(S) ) AND YOUNG PERSON (THE "PARTICIPANT") ARE GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. THEY ARE ALSO ASSUMING CERTAIN OBLIGATIONS AND GRANTING PERMISSION FOR EMERGENCY MEDICAL TREATMENT. NOTWITHSTANDING PRECAUTIONS TAKEN, ACCIDENTS OCCUR. THIS AGREEMENT MUST BE SIGNED IN ANTICIPATION OF THAT POSSIBILITY. To: HEART TO HEART CHILDREN S HOME IN HAITI SOCIETY (the "Society") In consideration of the Society sponsoring or being involved with a humanitarian trip to Haiti, particularly but not limited to the Heart to Heart Children s Home and School operated by the Society (the Haiti Trip ), in which the Society is permitting the Participant to be involved: 1. The Parent(s)/Guardian(s) and the Participant hereby: (a) (b) (c) (d) (e) (f) (g) (h) acknowledge that Activities referred to herein means the Haiti Trip and all things related thereto, including, but not limited to: travel to, from and within Haiti; accommodations; meals; childcare activities; building activities; physical activities; humanitarian relief work; and any other activities, functions, and events undertaken or attended during the Haiti Trip; acknowledge that transportation systems, housing accommodations, health care, public safety and other facilities in Haiti may vary greatly from what is normal or expected in North America; acknowledge that some or all of the Activities may involve private and/or public transportation; understand and acknowledge that some or all of the Activities may involve risks of harm to the Participant and/or damage to the property of the Participant, and that the likelihood of the occurrence of harm to the Participant and/or damage to the property of the Participant is not determinable; understand that unintended injuries and death may possibly result as a consequence of some or all of the Activities; accept full risk and responsibility for the death of or injury to the Participant and any damage to the property of the Participant arising from any of the Activities; waive any rights whatsoever that the Parent(s)/Guardian(s) and the Participant may have now or in the future against the Society and, as applicable, its members, directors, officers, leaders, agents, volunteers and employees as a result of the death of or injury to the Participant and/or damage to the property of the Participant arising from any of the Activities; release, forever discharge and covenant not to sue the Society, its members, directors, officers, leaders, agents, volunteers and employees from and in relation to all liability,
- 2 - actions, causes of action, suits, claims and demands whatsoever that may arise from any of the Activities; (i) (j) (k) (l) (m) (n) agree to indemnify and hold harmless the Society, its members, directors, officers, leaders, agents, volunteers and employees from any liability, costs, damages, expenses, actions, suits, claims and demands whatsoever arising from any negligent, wrongful or illegal act or omission of the Participant in respect of any of the Activities; represent that they have obtained, or will obtain prior to the commencement of the Haiti Trip, adequate travel insurance for the Participant covering the period from the commencement to the conclusion of the Haiti Trip; agree that in the event of a medical emergency occurring during the Haiti Trip, permission is granted to the Society and the Society s leaders to authorize necessary emergency treatment for the Participant, and that all costs and expenses incurred in connection with such medical treatment will be the responsibility of the Parent(s)/Guardian(s) and the Participant; agree and understand that this document and all permissions, consents, covenants, agreements, representations and understandings contained herein are irrevocable; agree and understand that this document will be binding on the heirs, executors, administrators and assigns of the Parent(s)/Guardian(s) and the Participant; and agree that if any provision hereof is invalid, illegal, or incapable of being enforced by reason of any rule of law or public policy then such provision will be severed from and will not affect any other provision contained herein, and this instrument will be read as if such invalid, illegal or unenforceable provision had never been contained herein and all other provisions hereof will, nevertheless, remain in full force and effect and no provision will be deemed to be dependent upon any other provision. 2. The Parent(s)/Guardian(s) further: (a) (b) affirm(s) that he/she/they is/are at least nineteen (19) years of age; and agree(s) to indemnify and holds harmless the Society, its members, directors, officers, leaders, agents, volunteers and employees from any liability, costs, damages, expenses, actions, suits, claims, and demands whatsoever arising from or related to the Participant s participation in any of the Activities. The undersigned acknowledge that they have read this waiver, understand that legal rights are being affected, and agree to the foregoing. DATE: Participant Signature Name (please print) Parent/Guardian Signature Name (please print)
- 3 - Date of Birth Address Contact number(s) Address Contact number(s) Parent/Guardian Signature Name (please print) Address Contact number(s)