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Medical Mission Waivers
Liability Waiver and Medical Release Form
I, (the “participant” or “Undersigned”), desire to participate as a volunteer in a short-term humanitarian mission trip (herein referred to as the "Mission Trip") with Partners for World Health, the Maine founded non-profit organization that is providing assistance in arranging this mission. In order to be considered an eligible candidate to participate in the Mission Trip, the Undersigned individual acknowledges and agrees to the following statements:
1. The participant will work to embody and respect the Partners for World Health mission statement and values stated in the Partners for World Health Policy Manual.

When departing on a mission trip, the Undersigned individual agrees to participate in all “team” aspects of the Mission Trip and understands that he/she is representative of Partners for World Health as an organization. A volunteer contract and agreement must be signed before any individuals are allowed to participate in any mission trip event.

2. The Undersigned understands and agrees that international travel and missions involve inherent risks, hazards and dangers, known and unknown, including but not limited to:
  • International political, social and economic conditions which are different than the United States and which can change in an unpredictable manner at any time during the Mission Trip
  • Unknown safety and maintenance of buildings
  • Poor and/or inadequate water and sanitation
  • Adverse weather conditions
  • Communicable diseases
  • Intentional and unintentional harm inflicted by third parties
  • Catastrophic injury including paralysis and death
  • Transportation hazards (air, train, automobile, other)
  • Acts of terrorism, civil unrest, war, or natural disasters
  • Exposure to region-specific pathogens and diseases
  • Variable and unpredictable access to medical treatment
  • Country-specific policies, standards, and cultures, as well as religious beliefs and conditions

I further understand and acknowledge that travelling on the Mission Trip exposes me to risks of a greater likelihood and magnitude than those normally associated with international travel.

All of the above listed, as well as other unforeseen hazards, could cause serious personal injury or loss of life to the participant and/or result in loss of or damage to property. The Undersigned hereby assumes all risk for any such personal injury, loss of life and/or property loss or damage that occurs while participant is on the Mission Trip or as a result of the participant’s participation in the Mission Trip. I understand that Partners for World Health and its representatives and agents cannot guarantee my safety and may not be in a position to provide emergency assistance to me if I need it.

3. The Undersigned understand that Partners for World Health is not responsible for any medical expenses the participant may incur before, during or after participating in the Mission Trip.
4. Partners for World Health may take any action it considers to be warranted under the circumstances regarding the Participant's health and safety.

The Undersigned hereby releases and indemnifies Partners for World Health from and for any liability it may incur in connection with such action. The Undersigned further understands that Partners for World Health does not provide the Participant with any form of insurance coverage while participating in this activity. It is recommended that the participant obtain insurance coverage that includes both accident and health insurance policies that would supplement the costs for medical treatment, evacuation, and repatriation if needed by the participant outside of the United States.

5. The Undersigned understands and agrees that:

Partners for World Health does not represent or serve as an agent for and cannot control the acts or omissions of transportation carriers, hotels and other suppliers of goods and/or services in connection with the Mission Trip. The Undersigned shall not hold Partners for World Health responsible for any personal injury to or loss of life of the Participant or loss or damage to the Participant's property that may be caused or contributed to by the act or omission of any suppliers of goods and/or services in connection with the Mission Trip.

6. The Undersigned agrees that:

The participant bears the sole responsibility for any and all travel expenses which he/she incurs in the event that Partners for World Health finds it necessary to send the participant home prior to the scheduled departure date, whether for health or physical limitations or inappropriate, or illegal behavior. The Undersigned further agrees and acknowledges that Partners for World Health is not and shall not be responsible for any injury the participant may suffer while traveling independently before or after the Mission Trip’s determined dates.

7. I have read this Liability Waiver and Medical Release

I know, understand and appreciate that these risks and other risks that are inherent in the Travel. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

8. I, for myself, my family, spouse, heirs, assigns, agents and all those in privity with me:

Do hereby release, waive, discharge, and covenant not to hold responsible Partners for World Health, its officers, employees, agents and representatives, individually and as a whole (hereinafter referred to as “Releases”), from any and all liability, claims, demands, actions and causes of actions whatsoever arising out of or relating to any loss, property damage or personal injury, including death, that may be sustained by me, or to any property belonging to me, arising from my participation in the travel.  I hereby voluntarily assume full responsibility for, and agree to indemnify and hold harmless the Releases from any and all liability, claims, demands, actions and causes of action arising out of any loss, property damage or personal injury, including death, that may be sustained by me, or to any property belonging to me, arising from my participation in the travel and to reimburse the Releases for any such expenses incurred, caused or by resulting in any way from my participation in travel.

10. This Agreement shall be governed by the laws of the State of Maine.

The undersigned further expressly agrees that the foregoing Liability Waiver and Medical Release is intended to be as a broad and inclusive as permitted by the law of the State of Maine, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

11. The Participant acknowledges that he or she has read this document.

The Participant understands that there is opportunity to ask questions concerning this document before signing, that no oral representations, statements or inducements apart from the foregoing written agreement have been made to the Participant, and that he or she voluntarily signs the same, thereby agreeing to be bound by all of the above.

With the intent to be legally bound, I acknowledge and represent that I have read this Liability Waiver and Medical Release Form, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement fully and voluntarily, and intend by my signature to be in complete and unconditional release of all liability to the greatest extent allowed by law.

 

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First Name
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Medical Mission Agreement

The sole purpose of my visit is to assist the medical mission team to provide services to patients. I agree to abide by the PWH mission and standard of practice at all times. I agree to follow acceptable rules of conduct, best practices and the laws of the United States as well as those of the country I am travelling to on the medical mission . I do not intend to use my trip for any other purpose whether under the name of Partners in World Health or not. I will not provide or publish any information to the media or other publishing outlets without prior written permission from PWH. I further agree to abide by the confidentiality requirements put forth by partnering organizations.

I understand that this is a voluntary mission and I am fully responsible for the financial costs of my trip. PWH does not take any responsibility for any financial, legal, or health-related costs for my trip or after for any acquired damages. I agree that I am participating at my own risk, and neither I nor my family will bring legal action against PWH or any of its representatives should I become injured, become ill, lose work or die as a result of my participation in this mission.

I, have read, fully understand, and hereby agree to comply with the rules, regulations and requirements presented and explained within this form. I represent that I have the professional or other training necessary for me to adequately and safely fulfill my identified role on this mission, Further, I, for myself, my estate, my heir’s and successors, hereby covenant and agree to hold PWH, its officers, directors, members, agents and employees harmless and to indemnify them from any and all liability for injury, loss, claims or damages from any cause to person or property, including, without limitation, my own, arising out of my involvement in the mission, all actions and travel related to the mission and conduct in connection with the mission, regardless of negligence.

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First Name
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Alcohol and Illegal Drug Policy
Use of Alcohol

Partners for World Health is a unique experience that allows participants to immerse themselves in the culture of a developing nation to provide medical, environmental, and community service. Issues of legality, liability, personal safety, and group cohesion are of a concern when alcohol is consumed on Partners for World Health trip. Excessive use of alcohol will not be tolerated. If alcohol consumption is not permitted in the country to which I travel on the medical mission, I shall not consume any alcoholic beverages while in the host country.

Use of Illegal Drugs

Partners for World Health has a zero tolerance policy regarding the possession, use, manufacture, production, sale, exchange, or distribution of illegal drugs (as defined by either United States Law or the laws of the country to which I am travelling) by students, faculty, and volunteers participating in the Medical Mission Trip. I will not attempt to bring any drugs (other than over the counter or prescription drugs for which I have a valid, current prescription from a physician) with me on the Medical Mission. 

Violation

I understand and acknowledge that in addition to putting myself at risk for prosecution in the host country or the United States, violation of this policy could cause substantial harm to Partners for World Health and its partners, as well as to Partners for World Health’s relationship with the host country. Violation of the Alcohol and Illegal Drug Policy is grounds for termination from the Partners for World Health Medical Mission Trip. Termination will result in the participant being sent home at his/her own expense.

I, hereby agree to follow the Alcohol and Illegal Drug Policy as set by Partners for World Health.

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First Name
Last Name