Jefferson Baptist Church Mission Trip Application. Name:

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1 Jefferson Baptist Church Mission Trip Application Name: I am applying to go to: (check all that apply) Portugal: June 23-July 4 Mexico: July Haiti: October Do you attend Jefferson Baptist Church? yes no Are you a member of Jefferson Baptist Church? yes no Have you served in missions before? (If yes, please include location and brief description.) Please include information as it appears on passport. Failure to do so may result in additional airline fees! Full Name (as it appears on passport): Address: Street City State Zip Phone: home cell work Address: Date of Birth: / / Place of Birth: Age: Passport Number: Issue Date: Exp Date: Driver s License Number: State: SSN: Marital Status: Single Married Divorced Widowed T-Shirt Size: S M L XL

2 Occupation: Place of Work: Other family members who are participating in this mission trip: Emergency Contact Information Who do you wish for us to call in case of emergency? Relationship to you: Phone Number: Address: If under 18 years of age, name and information of parent(s) or guardian(s): *Please note that a parental consent to travel is also needed. Phone: Briefly summarize your testimony: Please list current ministries you are involved in and ways that you use your gifts: Why do you want to participate in this mission trip? Describe what you think will be the biggest challenge for you to overcome on this trip:

3 Describe your strengths (gifts, talents, hobbies, personality, etc.): Describe your weaknesses: Do you have a criminal record? yes no If yes, please explain: Do you consent to a criminal background check? yes no Any additional comments: If I am a part of this team, I commit to the following: (Please initial) Praying and studying my Bible daily Attending training and follow-up meetings before and after this trip (or indicate if I cannot) Making sure all payments are taken care of by the deadlines given and before leaving on the trip Walking in integrity Being an active part of missions efforts in and around Baton Rouge and through Jefferson Baptist Church Honoring the guidelines and rules set forth by the host missionary, team leader and Jefferson Baptist Church Regular church attendance Usually, the best day of the week for me to meet to prepare for the trip is: (check all that apply) Sunday afternoon Monday night Wednesday after services Sunday night after services Tuesday night Thursday night Friday night Saturday daytime Saturday night

4 Jefferson Baptist Church Mission Trip Financial Agreement You are responsible for all financial costs of the mission trip(s) for which you are applying. If you have made commitments to the trip and later decide to drop out, you will be responsible to pay additional funds (up to the total cost of the trip). If Jefferson Baptist Church has already purchased airline tickets or has committed to other costs that cannot be refunded, you will be held responsible for those funds. Deposits are non-refundable, but we try to make arrangements for emergencies and special incidences out of the participant s control. Passports, vaccines, and meals on the day of travel are not included in the cost of the trip. Checks should be made out to Jefferson Baptist Church. Please turn checks in to Stephanie Hulett in an envelope marked with your name, the trip you are participating in, and the date you turned in the check. Please do NOT place trip checks in the offering plate or church safe. By signing below, I agree that I have read, understand, and agree to abide by the rules set forth above. Signature of Trip Participant Date If mailing a check, please address the envelope to: Jefferson Baptist Church Attn: Stephanie Hulett 9135 Jefferson Highway Baton Rouge, LA Non-Member Agreement Jefferson Baptist Church mission trips are open to Christians who are not members of Jefferson Baptist Church. The trip costs are different for non-members because the tithes and offerings of Jefferson members are used to subsidize the cost of their trip. If you do not attend Jefferson Baptist Church, please provide the following information: Name of the church you attend: Name of Pastor: Church Phone: Name of Reference (church member who knows you well):

5 Jefferson Baptist Medical Release Participant s Name: Age: Date of Birth / / SS# Address: City: State: Zip: Phone: In case of emergency, please notify: Address: City: State: Zip: Phone: Relationship to Trip Participant: Medical Profile Generally, participant s health is: (Check One) Excellent Good Fair Poor If fair or poor, please explain your condition: List any medical difficulties for which you are currently being treated: Check any of the following that cause you problems and explain: Asthma Sinusitis Bronchitis Kidney Trouble Heart Trouble Diabetes Dizziness Stomach Upset Hay Fever List any medicines, foods, or other substances to which you are allergic: List any previous operations or serious illnesses: List any medications you are currently taking, including doses: List any special diet or special needs: Childhood Diseases: Chickenpox Measles Mumps Whooping Cough Other:

6 Date of last Tetanus Immunization: *Note: A current tetanus immunization is required before participation in any Jefferson Missions trip is allowed. This is due to the limited availability of this immunization in the locations to which we travel. Family Physician: Phone: ( ) Insurance Information Insurance Company: Policy Number: Subscriber Name: Subscriber Number: Place of Employment: Release of Liability and Authorization for Medical Care I, the undersigned, do hereby grant permission for Jefferson Baptist Church staff, members, trip participants, or emergency medical personnel, to obtain medical care for me on my behalf. I give my consent and permission to the physician and/or hospital and/or other health care provider to provide medical or surgical treatment, including, without limitation, dental care, hospitalization, injection, anesthesia, invasive surgery or any other form or kind of medical or surgical care to me, emergency or as necessary, until such a time as I can provide consent. I further agree not to hold Jefferson Baptist Church or any of its staff members, church members, trip participants, or volunteers responsible for any accident that may occur on the way to, from, or during this trip. I indemnify, defend and hold harmless Jefferson Baptist Church, its staff members, church members, trip participants, and volunteers for all claims made and liabilities assessed against them arising from any event or activity in which I participate which was sponsored or organized by the church. I release Jefferson Baptist Church, its staff members, church members, trip participants and volunteers and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity in which I participate. I certify that I, or my child, has full medical insurance with the company listed above. I agree to allow the release of this information in the event of a medical emergency to a third party medical provider. I also certify that to the best of my knowledge, I or the participant named herein is physically fit to engage in activities with Jefferson Baptist Church. By signing below, I am acknowledging that I have read, understand and agree to the above statements. Signature of Participant, Parent or Guardian Date Sworn and subscribed before me, the undersigned notary, on the day of,. Notary Public in and for the State of Louisiana. Notary Name: My commission expires:

7 Media Release Form I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the student named above by Jefferson Baptist Church, its staff or volunteers. I also grant Jefferson Baptist Church, its staff and volunteers the right to edit, use, and reuse said media for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release Jefferson Baptist Church, its staff and volunteers from all claims, demands, and liabilities whatsoever in connection with the above. Signature of Participant, Parent or Guardian Date Property Damage and Disciplinary Action Agreement I understand and assume the expenses of any property damage caused by myself or my child. Should it be necessary that I or my child be returned home due to disciplinary action (when on trips), I will be contacted by the leaders and will be responsible to return home or to pick my child up. I understand and assume the cost of transportation. Signature of Participant, Parent or Guardian Date Parental Consent for International Travel Travelers under 18 years of age at the date of departure must present to the airline checkin representative a notarized letter of consent signed by BOTH parents or legal guardians for travel to any international destination. It is the sole responsibility of the trip participant to obtain proper citizenship documentation including a valid passport for all international destinations. To Whom It May Concern: We, the undersigned, give permission for our child,, to travel unaccompanied on a mission trip sponsored by Jefferson Baptist Church to on through. Parent or Legal Guardian 1: Signature: Relationship to Minor: Date: Parent or Legal Guardian 2: Signature: Relationship to Minor: Date: Sworn and subscribed before me, the undersigned notary, on the day of,. Notary Public in and for the State of Louisiana. Notary Name: My commission expires:

8 Jefferson Baptist Church Mission Trip Waiver ACKNOWLEDGMENT AND ASSUMPTION OF RISKS ATTESTATION AND AGREEMENT THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS. YOU MUST READ AND UNDERSTAND IT PRIOR TO SIGNING. For valid consideration, to include but not be limited to the assent of Jefferson Baptist Church to my voluntary participation in the 2015 Summer Mission Trip Program coordinated by and through Jefferson Baptist Church (hereinafter, the Program ), the receipt and sufficiency of which is hereby acknowledged and agreed, and intending to be legally bound hereby, I, (hereinafter, Participant ) for myself, my personal representatives, executors, administrators, successors, heirs, legatees, assigns, and next-of-kin, do hereby agree to the following: I UNDERSTAND, ACKNOWLEDGE, AND AGREE that the Program is being conducted in a foreign country that is not under the custody or control of Jefferson Baptist Church, and in the course of my participation in the Program, I will encounter persons not employed by, associated with, and/or affiliated with Jefferson Baptist Church. I FURTHER UNDERSTAND, ACKNOWLEDGE, AND AGREE that in the course of the Program, there exists certain risks, both known and unknown, which may include but shall not be limited to death, personal injury, and damage to property occasioned by and/or arising out of travel accidents, sickness, force majeure, and/or the uncontrollable or reasonably unforeseeable nature of encounters that may occur with persons of other cultures or beliefs, specifically to include those who may be hostile to the Program or to our group or individual members of our group on the basis of our faith, race, or national origin, and/or occasioned by circumstances and situations specific to the country(s) being visited, such as (but without limitation) civil unrest, violence, epidemics, and unstable governments. In addition, I understand, acknowledge, and agree that my participation in the Program may involve locations that may be remote and located substantial distances from available medical assistance and/or competent medical assistance. I understand that I have the duty to read the Travel Warnings and Consular Information presented by the U.S. State Department on the country(s) to which I will be traveling as part of the Program, which may be found at the following website ( cis_pa_tw_1168.html), and that Jefferson Baptist Church has no duty to inform me of same or update me as to any changes to same at any time. (All such conditions and risks referenced in the foregoing paragraph shall hereinafter be referred to individually and collectively as Risks.) I FURTHER UNDERSTAND, ACKNOWLEDGE, AND AGREE that Jefferson Baptist Church (inclusive of its agents) are acting solely as spiritual leaders and coordinators for the Program, but have assumed no legal duty to ensure my safety. Likewise, I understand, acknowledge, and agree that the Program and Jefferson Baptist Church (inclusive of its agents) cannot guarantee

9 my total safety inasmuch as some risks are beyond their control. I agree to follow all instructions and guidelines provided by the Program s leaders, and to act is a safe and responsible manner towards all Program participants and other third parties with whom I come into contact in the course of the Program. BASED ON THE FOREGOING, and being solely responsible for my own age, skill level, and physical condition (including physical problems such as cardiac conditions, hypertension, orthopedic problems, and other personal, pre-existing medical ailments), and the nature of the Program and the Risks outlined hereinabove, I FULLY UNDERSTAND, ACKNOWLEDGE, AND AGREE THAT MY VOLUNTARY PARTICIPATION IN THE PROGRAM IS INHERENTLY DANGEROUS AND MAY RESULT IN MINOR TO FATAL INJURIES, WHICH MAY INCLUDE BUT SHALL NOT BE LIMITED TO PROPERTY DAMAGE, PERSONAL INJURY, AND/OR DEATH. IN CONSIDERATION OF MY PARTICIPATION IN THE PROGRAM, I HEREBY KNOWINGLY AND WILLFULLY ASSUME ALL SUCH RISKS. I AM VOLUNTARILY PARTICIPATING IN THIS ACTIVITY WITH FULL KNOWLEDGE OF THE INHERENT DANGERS AND RISKS INVOLVED THEREWITH AND I HEREBY AGREE TO ACCEPT ANY AND ALL INHERENT DANGERS AND RISKS AND THOSE DAMAGES ASSOCIATED THEREWITH. In consideration of my participation in the Program, I/we hereby release Jefferson Baptist Church, Baton Rouge, La, and its members, employees, and agents from liability associated with the Program, to the fullest extent of governing law. I/we understand that there exists a risk of injury in the conduct of the Program as outlined hereinabove, which may be caused by my own actions and/or inactions, as well as the actions or inactions of other participants and third parties, the conditions in which the Program takes place, and/or the negligence of the Releasees, and that there may be other risks not known to me/us or not readily foreseeable at this time, and I/we fully accept and assume all such risks on behalf of myself, as well as all responsibility for all losses, costs, and damages incurred as a result of my participation in the Program. I/we hereby release and discharge, and waive liability of Jefferson Baptist Church, Baton Rouge, La, and its members, employees, and agents (individually and collectively, the Releasees ) for all liabilities, claims, demands, losses, costs, or damages, caused or alleged to be caused, in whole or in part, by the negligence of the Releasees or otherwise; and I/we further agree that if despite this release waiver, and assumption of the risk, I or anyone on my behalf, makes any claim against any one or more of the Releases, I will indemnify and hold harmless each of the Releasees from any loss, liability, damage, cost, or penalty, including attorneys fees and court costs, which any Releasee(s) may incur as the result of such claim or demand. Further, In the event of any injury or illness to my person during the Program, I understand that Jefferson Baptist Church, Baton Rouge, La will undertake reasonable efforts to attend to my injuries or illness, but I understand, acknowledge, and agree that the conditions of the area into which I am going may preclude the same kind of care and treatment otherwise available to me in the United States, and therefore in connection with any treatment and/or medical care provided to me in the event of an injury or other emergency during the Program, I hereby covenant to treat Jefferson

10 Baptist Church, Baton Rouge, La and its representatives as Good Samaritans and absolve them from any and all liability associated with my treatment and care to the fullest extent of the law. I agree and understand that the Program is purely voluntary and that if I am not willing to acknowledge and accept the entirety of the aforementioned risks, I shall not participate in the Program. I HAVE READ THE ENTIRE CONTENTS OF THIS ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS ATTESTATION AND AGREEMENT DOCUMENT AND I NOW FULLY UNDERSTAND AND ACKNOWLEDGE THAT MY VOLUNTARY PARTICIPATION IN THE PROGRAM IS AND FOREVER WILL BE AT MY OWN RISK; THAT BY SIGNING THIS DOCUMENT, I HAVE SIGNIFICANTLY INCREASED MY AWARENESS OF THE RISKS ASSOCIATED WITH THE PROGRAM; AND THAT THIS INCREASE IN KNOWLEDGE WILL HAVE SIGNIFICANT LEGAL IMPLICATIONS IN THE EVENT OF LITIGATION. FURTHER, I have read this Acknowledgment and Assumption of Risks Attestation and Agreement, including the section(s) concerning release, hold harmless, and indemnification rights, and I understand that I am giving up certain, substantial rights by signing it, and I am signing it freely and without any inducement or assurance of any nature, other than the provisions contained herein. I intend for this to be a full and complete release of all liability to the fullest extent allowed by the laws of the State of Louisiana, which shall govern the interpretation of same without regard to the conflicts of laws provisions thereof. If any portion of this Acknowledgement and Assumption of Risks Attestation and Agreement is held by a court of competent jurisdiction to be invalid or unenforceable, it is agreed that the remainder shall remain fully in force and in effect. This constitutes the entire agreement between the undersigned and Jefferson Baptist Church, Baton Rouge, La, and there are no other writings, instruments, agreements, contracts, notations, or promises, whether written, oral, or electronic, existing between the parties with respect to the subject matter hereof, and all prior agreements are hereby superseded. Participant s Printed Name: Participant s Signature: Date:, 2016 If Program Participant is under 18 years of age: Parent/Guardian Printed Name(s): Parent/Guardian Signature: Date:, 2016 Sworn and subscribed before me, the undersigned notary, on the day of,. Notary Public in and for the State of Louisiana. Notary Name: My commission expires:

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