MPDR 6

PARTICIPANT LIABILITY RELEASE FORM And EMERGENCY MEDICAL CARE AUTHORIZATION

(Please read before signing, as this constitutes the agreement as a volunteer and the understanding of your working relationship with Mission Presbytery Disaster Response and Mission Presbytery.)

I, __________________________, acknowledge and state the following: I (or Parent/Guardian of a minor), have chosen (or have chosen to have my child) to participate and travel to the work site to perform cleanup/construction work in disaster, "Hands of Help Projects", and Humanitarian relief.

I understand this work entails a risk of physical injury and often involves hard physical labor, heavy lifting and other strenuous activity; and some activities may take place on ladders and building framing other than on ground level. I certify I am in good health and physically able to perform this type of work.

I understand I am engaging in this project at my own risk. I understand this is a "grass roots" activity to support individuals adversely affected by disasters and other Mission Presbytery "Projects". I accept and assume all responsibility for my personal actions and any and all risk of my and others property damage and/or personal injury which may occur during or result from my participation, which I may sustain while involved in this project, and related material costs and expenses.

With the above in mind, I fully understand and agree that Mission Presbytery, a Corporation, the Sponsor, their staff members, successors, assigns, officers, agents representatives, and entities 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 the "Project", or any portion of the "Project", even if said injury is due to the alleged negligence of Mission Presbytery or others.

I do hereby agree to indemnify and hold Mission Presbytery harmless against and from any and all liabilities, damages, claims, suits, judgements, and associated costs and expenses (including, without limitation, reasonable attorneys' fees) of whatsoever kind in connection with the "Project" or portion of the "Project".

In the event that Mission Presbytery Disaster Response and Mission Presbytery arranges accommodations, I understand they are not responsible nor liable for my personal effects and property and they will not provide lock up or security for any items. I will hold them harmless in the event of theft resulting from any source or cause. I further understand I am to abide by whatever rules and regulations may be in effect for the accommodations at that time.

By my signature, for myself, my estate and my heirs, I release, discharge, indemnify and forever hold Mission Presbytery Disaster Response and Mission Presbytery together with their officers, agents, servants, and employees, harmless from any and all causes of action arising from my participation in this project, and travel or lodging associated therewith, including any damages which may be caused by their own negligence.

If unable to give consent for Medical Care because of my physical or mental condition, I authorize emergency medical care decisions to be made on my behalf, and I specifically release Mission Presbytery in making those emergency care decisions even if injury or death is the result of Mission Presbytery alleged negligence.

I HAVE READ CAREFULLY, AGREE TO, AND INTEND TO BE LEGALLY BOUND BY ALL TERMS OF THIS HOLD HARMLESS, WAIVER OF LIABILITY AND EMERGENCY CARE AUTHORIZATION.

Date: ___________________________________ Date of last Tetanus:_______________________________

Signature: ______________________________ Address: ________________________________________

Person to contact in case of an emergency: ___________________________________________________________

Telephone: _________________________________

RETURN TO:

Singletary H. Snyder - Mission Presbytery Disaster Response Coordinator, Mission Presbytery

1015 North Sunset Canyon Drive, Dripping Springs, Texas 78620 - (512) 892-6800 / Fax: (512) 288-5595