(COPY AS NEEDED)
AND PARENT
PERMISSION FORM
Cross Culture
Experiences, Inc. (dba Mission Waco)
Required for the following activities: Check all that apply for this release.
___ Poverty Simulation, Waco, TX
___ Climbing Wall at Jubilee Center, 1319 N. 15th, Waco, TX
___ Out of Country Mission/Exposure Trip: Specific which country - ____________________
___ Special Outing or Field Trip: Describe _________________________________________
___ Mission Waco Program(s) including transportation: Describe _______________________
_X_Volunteerism in Mission Waco programs
_X_Construction/Work Projects
Whereas, the undersigned participant wishes to be accepted for participation in one or more of the activities listed above which is organized by Cross Culture Experiences, Inc. / Mission Waco, of Waco, TX and regarding Cross Culture Experiences, Inc. / Mission Waco’s action in allowing the applicant to participate in such activities or programs, the undersigned acknowledges that the activity does involve certain risks. The activities are designed to allow the participant to broaden their understanding of various Christian values, socio-economic differences, ethnic and racial diversity, cultural appreciation, team building, character development, and/or enrichment opportunities. These activities include those listed above, but are not limited to, and activities in a lower income neighborhood and among poor people in Waco, TX, other communities, and foreign countries. I understand that participants are exposed to physical and psychological risk through elements of nature, travel by car, van, plane, walking, or other conveyance, and direct contact with people from various backgrounds. Risks may also include damage or loss of personal property. I further understand that immediate medical treatment may be difficult or delayed, especially in foreign countries. Risks may also include physical injury and/or strenuous physical activity at work/construction sites, the Climbing Wall, or during other activities.
In consideration of the above, I have and do hereby assume all the above risks and any other ordinary risk incidental to the nature of the program, including risks which are not specifically forseeable, and will hold harmless and indemnify Cross Culture Experiences, Inc. / Mission Waco, its Board of Directors, employees, agents, and/or Associates from any and all liability. The terms hereof, and my signature on this document shall serve as a release and assumption of risk, and shall bind my heirs, representatives, executors, administrators, successors and assigns and for all members of my family, including any minors accompanying me. I also state that I am not under, and will not be under the influence of any non-prescribed chemical substance, including alcohol. I also state that I will assume responsibility for any damage or loss to physical property or expenses incurred due to negligent or irresponsible behavior. I understand that my participation in this Cross Culture Experiences / Mission Waco program or activity is entirely VOLUNTARY.
My signature also gives my permission and accepts financial responsibility, as well, for first aid treatment and/or professional medical attention if needed. I also give permission for photographing of myself or my child during the activities and use of those pictures or video by Cross Culture Experiences, Inc. / Mission Waco.
_______________________________ _________ ______________________________ ___________
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Please print
legibly – Each participant must complete this section:
Participant Name: ______________________________ Age: ______________ Phone: ( ) ____________
Address: _____________________________________ City: ______________ Zip: ______________________
In case of emergency, please contact: ______________________________________ Phone: ( ) ____________
Contact’s relationship to participant: _______________________________________________