Participants Name

First Name

Last Name

Birthday

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Email Address

Please Read and Select Yes or No

If Participant is under 21, Participant's Parent or Legal Guardian must read and type their name in the designated field at the bottom of this form. By selecting "yes" you signify your understanding of and agreement with each statement.

Select Yes or No

I authorize In His Steps International, its agents, Board of Directors, staff, and any associated volunteers (hereafter referred to as "IHSI"), to release any and all medical information or records to any party deemed necessary by IHSI, and to assign for the providing of medical treatment to the Participants. I also release and agree to indemnify IHSI for any and all damages, liability, or costs resulting from the authorizing of medical treatment provided or authorization for treatment provided.

Select

Select Yes or No

I am aware that serious illness or injury may occur on during my stay abroad and that such illness and injury may result in the Participant or myself incuring costs, expenses, and damages for which I am solely responsible, including but not limited to, returning of Participant by air ambulance or other extraordinary means. I also understand that missions trips may be associated wth risk of bodily harm, death, and/or damage to or loss of personal possessions resulting from, without limitation, inclement weather, transportation accident, or terrorism. I personally assume all such risks, whether foreseen or unforeseen by IHSI or Participant. I hereby release and hold blameless IHSI from all liability for personal injury, including death, as well as all property damage or loss arising out of Participant's participation in in this stay abroad. I understand that this release and indemnification also releases liability for the conduct of IHSI.

Select Yes or No

I understand that certain circumstances may occur resulting in Participant's need for medical/dental care or treatment and further resulting in Participant or Participant's Parents/Legal Guardians inability to personally give consent for such care and treatment. In consideration of permission from IHSI for Participant to particiate in In His Steps International ministry, the Participant (or Participant's Parents/Legal Guardian) authorizes IHSI or any of its designated agents to act on Participant's behalf should Participant be unable to do so and to consent to all medical/dental care and treatment, including but not limited to diagnostic tests, x-ray examination, anesthesia, surgery, or other procedures which IHSI deems necessary for Participant's well-being for the duration of my stay abroad. This consent is given in advance of any specific diagnostic tests, treatments, surgeries, or medications, and is given to provide authorization and specific consent for medical/dental treatment and care on Participant's behalf. Any consent given by IHSI shall have the same force and effect as if Participant (Participant's Parents/Legal Guardians) had personally given consent.

Select Yes or No

I have read and understand the above information. My signature below signifies my approval of all limitations lsited above as well as my agreement with the accountability/behavioral agreement and gives IHSI the right to use my picture, voice, and/or testimony in any form of ministry related promotional materials.

Select Yes or No

Participants Name

Electronic Signature

Parent or Legal Guardian Signature

If the Participant is under 21, parent/guardian signature is required below.

Parent or Legal Guardian Signature

Electronic Signature

In His Steps International

In His Steps International

Release of Liability

In His Steps International

In His Steps International

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