Part A - To be completed if participant is an adult

I, __________________________, will be going on the Mexico Mission Trip with People Building People from __________________ to __________________, 2______ (dates of trip).

Part B - To be completed by parent or legal guardian if participant is a minor (under age of 18)

I give permission for my minor child, _____________________ (name of child), to go on the Mexico Mission Trip with People Building People from ___________________ to _________________, 2______ (dates of trip).

Part C - To be completed by everyone

I fully understand that participation in this mission trip may result in illness, accident or injury. I have been afforded every opportunity to conduct my own investigation of the conditions surrounding this trip and certify that participation in the trip is a matter of free choice. I am specifically aware that certain hazards and risks are associated with serving in a mission capacity, including but not limited to death or injury by accident, disease, war, terrorist acts, adverse weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence or negligence. On behalf of the participant, I hereby assume these risks and release in full any claims of any type against People Building People and its officers, directors, agents, and employees. I can be reached at the following telephone numbers during the day _____________________ (phone number) or evening ___________________ (phone number). Should it be necessary for the participant to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The participant has the following allergies, medical conditions, or other special concerns of which People Building People should be aware:
__________________________________________________________
__________________________________________________________
__________________________________________________________

Part D - To be completed by everyone

We (I) authorize People Building People or any adult on this trip in whose care the participant has been entrusted to consent to any medical examination or treatment, including hospital care, to be rendered to the participant by a duly licensed physician or dentist. We (I) agree to be liable for all expenses incurred in connection with such medical and dental services rendered to the participant pursuant to this authorization.

Insurance Co. ______________________ Policy #: _______________
Address: _____________________ City: _____________ State: ___
Hospital Insurance: _____ Yes ______ No
Emergency Numbers
Doctor: ____________________________ Phone #: _________________
Other: __________________ Relationship: ________ Phone #: _________

Signatures

___________________________Date:____________
Signature of Adult Participant

___________________________Date:______________
Signature of Parent/Guardian** (#1)

___________________________Date:______________
Signature of Parent/Guardian** (#2)

______________________________ Date:_______________
Notary** (Required if participant is under age 18 with no parent/guardian on trip)

** This needs to signed by both parents or guardians and notarized if both parents are not on the trip for youth under 18 years of age.