WAIVER Medical Release One per person to be collected by local team leader and sent to UTRI In being accepted and allowed to participate in the by utz16046


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Medical Release
(One per person to be collected by local team leader and sent to UTRI.)
In being accepted and allowed to participate in the Upon This Rock International Short Term Team
Program and activities associated with its program and location, I assume responsibility for my actions.
I release Upon This Rock International (UTRI), its trustees, employees, missionaries and agents from
liability, loss, injury or damage to my property or myself.
Nothing contained herein shall excuse UTRI, its trustees, employees, missionaries or agents from
responsibility to act with reasonable care for the safety of my property or myself.
I hereby release UTRI, its staff, trustees, employees, missionaries, agents or sponsors of this activity from
responsibility and liability for any injury or illness that I may sustain during this activity.
In the event of an emergency, I hereby authorize an adult leader of this activity (affiliated with UTRI) as
an agent of me, to consent on my behalf to medical treatment. In this regard I consent to allow said adult
to authorize medical, dental or surgical diagnosis; X-ray examination; treatment including surgery, and
hospital care for me if needed and if advised and supervised by a licensed physician, surgeon or dentist.
Photo Release Form
I grant permission to Upon This Rock International (UTRI), its agents or staff, to use photographs taken
of me during the time spent during my mission trip for use in ministry publications such as brochures,
newsletters, and magazines, and to use the photographs on display boards, and to use such photographs in
electronic versions of the same publications or on the ministry website or other electronic forms of media
without notifying me.
I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter
that may be used in conjunction with them now or in the future, whether that use is known to me or
unknown, and I waive any right to royalties or other compensation arising from or related to the use of the
photograph. Initial________
I have read and agree to the UTRI handbook. Initial________
Name: __________________________________________________________________
(Please type or print)
Signature: _________________________________ Date: ________________________

Signature of Parent or Legal Guardian:______________________________________
(If under 18 yrs of age)
Emergency Contact Information

Name_________________________________ Relationship _______________________

Address _________________________________________________________________

Home Phone:__________________________ Work Phone: _______________________

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