2020-2021 Immersion/Mission Trip Program
Consent to Participate & Release of Liability
FORM MUST BE SUBMITTED BY April 30
Name of Mission Trip
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Christian Appalachia Project Trip - June 6-11, 2021
HOPE Emergency Service Days - June 7-9, 2021
Student Name
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First
Last
TERMS AND CONDITIONS FOR PARTICIPATION: The undersigned is/are the custodial parent(s) or legal guardian(s) of the Student and hereby request that his/her/their child participate in the Immersion/Mission Trip described above and consent to the Student’s participation on these terms and conditions. The undersigned recognize(s), agree(s) and understand(s) that the dates of departure and return are subject to change and that transportation may be provided by the School, a common carrier, or other means. The undersigned consent(s) to the Student’s participation on the dates shown above, to any adjustment in those dates and to the use of the form of transportation actually used during any and all parts of the Immersion/Mission Trip. The undersigned understand(s) that it is necessary to have rules and regulations respecting the behavior of the School’s students on the Immersion/Mission Trip (“Student Code of Conduct”) and hereby agree(s) to abide by such rules and regulations as may, from time to time, be enacted by the school.
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I agree
Each Student and her parent, guardian, or custodian agrees that (1) it is their sole responsibility to evaluate carefully the risks inherent in the trip; (2) they have fully considered and are fully aware of the risks inherent in the trip including, without limitation, dangers posed by international travel and willful or negligent conduct by the Student and/or by others; (3) by participating in the Immersion/Mission Trip, they are voluntarily assuming these risks and any other risks; and. (4) Student’s participation in the Immersion/Mission Trip is purely voluntary and is a privilege and not a right.
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I agree
The undersigned understand(s) that the Student shall be responsible for exercising due care and caution to avoid criminal violations, violations of the Student Code of Conduct, and injury, illness or death to themselves and/or others. If the Immersion/Mission Trip includes international travel, the legal systems in many foreign countries are very different from the United States and the Student shall be held accountable for her own actions under the laws of those countries.
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I agree
The undersigned is aware that if the Immersion/Mission includes international travel, the medical programs and medical cost arrangements in other countries may be different from those in the United States. St. Ursula Academy shall not be responsible for paying for any type of medical treatment for the Student. A Medical Power of Attorney and Permission Form will be provided to each Student. This Form must be filled out completely, signed by the custodial parent or legal guardian and returned to the appropriate school personnel. If St. Ursula Academy does not receive the signed Medical Power of Attorney and Permission Form before the Immersion/Mission Trip departure date, the Student will be prohibited from participating in the Immersion/Mission Trip.
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I agree
The undersigned understand(s) and agree(s) that each Student traveling outside the United States is required to obtain a valid U.S. passport, any necessary visas and/or any other required documentation for the Immersion/Mission Trip, at her own expense. Inability to obtain the necessary travel documents before the departure date will preclude the Student from participating in the trip.
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I agree
The undersigned further agree(s) and understand(s) that the Student participates in the Immersion/Mission Trip at his or her sole risk and the undersigned, on his/her/their behalf and on behalf of the Student, assumes full responsibility for any injury, loss or damages incurred in connection with the Student’s participation in the Immersion/Mission Trip. The undersigned, individually and on behalf of the Student, agrees to forever release, discharge, and hold harmless St. Ursula Academy, its trustees, teachers, employees, agents, any parent or volunteer who participates as a chaperone, administrators, executors, successors and assigns from any and all liability, claims, actions, judgments, demands, damages, costs, and expenses, including attorneys’ fees, that relate in any way to the Student’s participation in the Immersion/Mission Trip, including any injury, illness, death, loss of personal property (i.e. monies, luggage, passports) incurred by the Student while participating in or traveling to or from the Immersion/Mission Trip.
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I agree
The undersigned agree(s) that Saint Ursula Academy and its agents may use a photograph, video, or other likeness of the Student for promotional purposes, website and office functions and use social media and technology to communicate to the Student regarding ministry related activities.
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I agree
I disagree. (Saint Ursula Academy DOES NOT have my permission to use a photograph, video, or other likeness of the Student for promotional purposes, website and office functions and use social media and technology to communicate to the Student regarding ministry related activities.)
This Consent to Participate & Release of Liability is intended to be as broad and inclusive as permitted by the law of the State of Ohio, and if any portion hereof is declared invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This Consent to Participate & Release of Liability shall be construed in accordance with the laws of the State of Ohio, except for the choice of law provisions thereof. The undersigned has/have carefully read and understand and accept the terms and conditions stated herein and acknowledge that this Consent to Participate & Release of Liability and the accompanying Medical Power of Attorney & Permission Form shall be effective and binding on me/us, the Student, and my/our own and the Student’s personal representative or estate, assigns, heirs, and next of kin and that I/we have signed this Agreement of my/our own free will.
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I agree
Parent #1 Name
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First
Last
Parent Email
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Enter Email
Confirm Email
Parent #1 Signature
Are you having difficulty signing above?
Yes
No
I acknowledge that I am having difficulty with the electronic signature portion of this form. However, by initialling below I am indicating that I agree with the terms and conditions laid forth above in this Consent to Participate in Mission/Immersion Trips form.
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Date
MM slash DD slash YYYY
Parent #2 Name
First
Last
Parent #2 Signature
Are you having difficulty signing above?
Yes
No
I acknowledge that I am having difficulty with the electronic signature portion of this form. However, by initialling below I am indicating that I agree with the terms and conditions laid forth above in this Consent to Participate in Mission/Immersion Trips form.
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Date
MM slash DD slash YYYY
Please upload a copy of your daughter's Health Insurance Card (front and back required)
**PLEASE NOTE - uploaded photographs must not exceed 3 MB
Max. file size: 1 GB.
Do you need to upload another file so that we have the front and back of your daughter's insurance card?
Yes
No
File #2 for Health Insurance Card
**PLEASE NOTE - uploaded photographs must not exceed 3 MB
Max. file size: 1 GB.
As you plan for your Mission Trip experience this summer, your safety is the highest priority, therefore we request that you indicate the last date of your Tetanus shot. If this is not up to date, please make arrangements in this regard.
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Please list the date of your daughter's last tetanus shot.
Student Full Name as it appears EXACTLY on your passport.
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Student name EXACTLY as it appears on government issued ID:
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(License, passport, etc)
Student birthdate
*
MM slash DD slash YYYY
Passport Number (required)
Passport Expiration Date (required)
Please note that your passport must be valid through December 2019 in order to travel outside of the country.
MM slash DD slash YYYY
Country where passport was issued (if other than USA)
Please upload a copy/photograph of the page of your passport book which contains the above information (required)
**PLEASE NOTE - uploaded photographs must not exceed 3 MB
Max. file size: 1 GB.
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