GENERAL RELEASE, INDEMNIFICATION AGREEMENT AND

AUTHORIZATION FOR MEDICAL TREATMENT

Participant name: _________________________________________________(“Participant”)

 

DOB: __________________________________

 

Address: ____________________________________________________________________

 

City/State/Zip: _______________________________________________________________

 

Telephone: (Cell) ___________________(Day/Evening)______________________________

 

In consideration of the opportunity provided to me to participate in the PDA Disaster Response (as defined below) and any services, housing, food, and the like provided by PCUSA (as defined below), I, Participant, hereby understand and agree that the Presbyterian Church (U.S.A.) General Assembly, all synods, presbyteries, and local churches and their corporations and related entities, their staff, volunteers, directors, officers, agents, elders, deacons, representatives, successors, assigns and entities (hereinafter collectively referred to as "PCUSA") will not be responsible in any way whatsoever for loss, damage, or injury of any kind or in any manner resulting from or in connection with my participation in the program described as follows: __________________________________________________________________________________________________________________________________________________________________________

 

(hereinafter referred to as "PDA Disaster Response").

 

I, Participant, understand and agree that PCUSA does not and cannot guarantee my safety in connection with the PDA Disaster Response. Further, I understand and agree the activities involved with the PDA Disaster Response may include but are not limited to the following: difficult living conditions, risks concerning means of travel, food, water, diseases, pests, poor sanitation, and other health related situations, including potential injury while working. I accept and assume all responsibility for all risks which may occur during, in connection with, or result from my participation in the PDA Disaster Response including, but not limited to, potential injury while working.

 

RELEASE: With the above in mind and by my signature below, I fully understand, agree and hereby voluntarily release and forever discharge PCUSA. PCUSA shall not be responsible or liable in any way for any accident, loss, death, injury or damage to myself or my property, in connection with my participation in the PDA Disaster Response or any portion of the PDA Disaster Response even if said injury or action is due to the alleged negligence of PCUSA. Further, I do hereby agree to indemnify and hold PCUSA harmless against any and all liabilities, damages, claims, actions or rights of action, suits, judgments and associated costs and expenses (including, without limitation, attorneys' fees) of whatsoever kind in connection with my participation in the PDA Disaster Response or any portion of the PDA Disaster Response. Further, I make this agreement on behalf of my heirs, agents, fiduciaries, successors and assigns. I waive, knowingly and voluntarily, each and every claim or right of action I have now or may have in the future against the PCUSA related to my participation in the PDA Disaster Response, even if any such claim or right of action is caused by PCUSA's alleged negligence. This document does not release PCUSA from gross negligence.

 

 

 

 

 

MEDICAL COVERAGE: I understand and acknowledge that no medical or other insurance or health care benefits will be provided to me by PCUSA during my participation in the PDA Disaster Response, and I certify that I have sufficient health, accident and liability insurance or other benefits to cover any bodily injury or property damage I may incur while participation in the PDA Disaster Response and to cover bodily injury or property damage caused to a third party as a result of my participation in the PDA Disaster Response, as follows:

 

Company _____________________________Policy #_____________________________

 

MEDICAL RELEASE: I hereby state that I am in good health and have all medications necessary to treat any allergic or chronic conditions, and I am able to administer such medications without assistance. If at any time during my participation in the PDA Disaster Response I need emergency medical care and am not able to give consent because of my physical or mental condition, I authorize PCUSA to make emergency medical care decisions on my behalf, and I specifically release PCUSA, in making those emergency medical care decisions, from any and all liability associated with said decisions, even if injury or death is the result of PCUSA's alleged negligence.

Person to be notified in case of injury:

Name _______________________________________________________________________

Telephone: _______________________ (evening)______________________________(daytime)

Cell Phone: _________________________________________

 

ALL PARTICIPANTS MUST SIGN:

 

My signature below indicates that I have read this entire two page document, understand it completely, and agree to be bound by its terms.

 

SIGNATURE OF PARTICIPANT: __________________________________________

 

DATE EXECUTED: ______________________________________________________

 

SIGNATURES MUST BE WITNESSED:

 

SIGNATURE OF WITNESS: _____________________________________________

 

DATE EXECUTED: _____________________________________________________

 

(SIGNATURE OF PARENT OR LEGAL GUARDIAN IS ALSO REQUIRED IF PARTICIPANT IS UNDER 18 YEARS OF AGE.)

 

SIGNATURE OF PARENT/LEGAL GUARDIAN (if applicable)_________________________

 

SIGNATURE OF WITNESS: _____________________________________________

 

DATE EXECUTED: _____________________________________________________