Release and Liability Form

First Name *

Last Name *

Email Address *

Home Phone Number

Cell Phone Number

Address

Emergency Contact

Emergency Contact's First Name *

Emergency Contact's Last Name *

Relationship *

Phone Number

Medical Information

Any past or current medical history that could require medical care while working on a LEAP mission? (i.e., diabetes, seizures, allergic reactions, etc.):

Are you taking any medication(s)?

If so, please list:

Provide any relevant past surgical history:

List any known allergies and reactions:

Personal Physician Information>/h4>

Name of Personal Physician

Phone Number

Medical Insurance Information

Company Name

Phone Number:

Group Policy Numbers

Member ID:

Release and Waiver of Liability

THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR LEGAL RIGHTS.

THIS RELEASE AND WAIVER OF LIABILITY (herein "Release") is executed on the below date by the undersigned volunteer (herein "Volunteer") in favor of LEAP Global Missions, a non-profit corporation, its directors, officers, employees, and agents (collectively "LEAP"). The Volunteer desires to provide volunteer services for LEAP and engage in activities related to being a Volunteer. The Volunteer understands that no compensation is expected in return for services provided; that LEAP will not provide any benefits traditionally associated with employment to the Volunteer; and that the Volunteer is responsible for their own insurance coverage in the event of personal injury or illness as a result of the Volunteer's services. As an inducement to LEAP to accept the Volunteer's scope of volunteer work, the Volunteer does hereby freely execute this Release with understanding and acknowledgment of the following terms:

1. Waiver and Release: The Volunteer does hereby and forever discharge and hold harmless LEAP and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or equity, which arise or may hereafter arise, either directly or indirectly, as a result of Volunteer's work for LEAP. The Volunteer understands and acknowledges that this Release discharges LEAP from any liability or claim that the Volunteer may have against LEAP with respect to any bodily injury, illness, death, and/or property damage that may result from the Volunteer's work for LEAP, whether caused by the negligence of LEAP or its officers, directors, employees, other volunteers, agents, or otherwise.

2. Assumption of Risk: The Volunteer recognizes that the conditions in some of the places in which LEAP may travel to provide medical/surgical care are not equal to the same standard of conditions for which most of us are accustomed. The Volunteer further understands there are certain health and detainment risks to self and property and hereby fully enters into participation of the LEAP mission with knowledge of these risks. The Volunteer will make every reasonable effort to be knowledgeable and respectful of the host country's culture and people. The Volunteer acknowledges there may be certain risks and hazards that could involve dangerous and/or hazardous activities and expressly assumes the risk of any injury or harm from such activities. Further, the Volunteer agrees to practice safe travels and at all times act in accordance expected of a professional while working as a Volunteer for LEAP.

3. Photographic Release: The Volunteer does hereby grant and convey unto LEAP the right to freely reproduce and/or circulate any photographs or other recordings of the Volunteer for any lawful purpose. The Volunteer shall not be entitled to any compensation, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

4. Privacy and Confidentiality: The Volunteer agrees to maintain the privacy and confidentiality of the patients, their families and/or host families, as well as to the other medical, surgical and non-medical Volunteers involved with LEAP during the course of a mission, as reasonably appropriate. Some sensitivity with regard to a host country may also be required under certain circumstances.

5. Medical Treatment: As a Volunteer, I hereby release and forever discharge LEAP from any claim whatsoever that arises or may hereafter arise for any first-aid treatment and/or other medical services rendered in connection with treatment and/or an emergency during my Volunteer tenure with LEAP. As a Volunteer, I understand that LEAP does not assume any responsibility for providing any financial or other assistance, including, but not limited to, medical, health, dental, or disability benefits or insurance of any nature in the event of injury, illness, death, and/or damage to property. Further, as a Volunteer I agree to provide any and all medical history that may require medical treatment while traveling and engaging in activities as a LEAP Volunteer, particularly if emergency medical treatment may be required.

Signature (If 18 or older) *

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To be signed by Parent or Guardian of Volunteer if Under Age 18

Name(s) of Minor(s)

Signature of Parent/Legal Guardian

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Emergency Contact

Medical Information

Personal Physician Information>/h4>

Medical Insurance Information

Release and Waiver of Liability

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