You Need a Witness!

In order to complete the Waiver below, you will need a second person
to sign as a witness to your agreement to this waiver

Short Term Mission Trip Waiver

By signing your FULL NAME in the SIGNATURE BOX, you agree to the following:


Vision Outreach International Inc. (VOI)
2848 Niles Road, Saint Joseph, MI  49085
Surgical Eye Mission (of below selected location and date)

This Agreement must be completed to participate in the activities associated with the VOI Surgical Eye Mission (of the below-selected location and date).

I, the undersigned, am familiar with the nature of the activities that will take place at the VOI Surgical Eye Mission (of the below-selected location and date) (hereinafter referred to as the “event”), and I desire to participate in it. I hereby acknowledge that my participation in this event is voluntary.

I recognize that there are foreseeable and unforeseeable risks and hazards directly or inherently involved in my participation in this event and that the event sponsors have no control over such dangers and make no representations of safety. I further acknowledge that I fully know the facts and circumstances associated with participating in this event. If I choose to participate in this event, I voluntarily assume all responsibility and risk, including but not limited to all risk of loss of limb or life; physical and emotional injuries; serious illness such as infectious and non-infectious diseases and/or conditions arising from my participation in this event or associated with developing or pre-existing conditions, accidents, property damage, injury to others, and other hazards.

In consideration of being permitted to participate in this event, I agree to follow the reasonable guidelines set forth by the event sponsors for the duration of the activity, to be fully responsible for my conduct, and to always act in a manner that does not jeopardize the safety of myself or other persons. I also state that during this event, if I cannot act on my own behalf, I authorize the event sponsors to take all action on my behalf as reasonably necessary.

I understand and acknowledge that Vision Outreach International Inc. is limited in its ability to maintain insurance to provide coverage for event participants’ injuries. I understand that Vision Outreach International Inc. is not an insurer of participants’ behavior and actions and that Vision Outreach International Inc. assumes no liability whatsoever for personal injuries or property damages to participants or third persons arising from participating in this event’s activities. Though VOI provides basic travel and evacuation insurance, I assure the event sponsors that I will have adequate liability, health, and accident insurance or other means necessary to pay any additional expenses for any personal liability and medical costs, including medical evacuation that may directly or indirectly result from my participation in this event. I will indemnify and hold Vision Outreach International Inc. harmless.

To the extent permitted by law, I hereby agree to a covenant not to sue and to indemnify, release and hold harmless Vision Outreach International Inc. (hereinafter referred to as “Releasees”) from all liability whatsoever arising out of my participation in this event, including but not limited to any claims, demands, actions and causes of action related to any damage to my property or the property of others, and injury to me or others, including but not limited to loss of limb or life resulting from my negligence or the negligence of others, or to others through my actions during this event or arising out of this event. I agree to pay any attorney fees or other costs incurred by the Releasees in enforcing this Agreement.

It is my express intent that this Release shall bind the members of my family and spouse, if I am alive, and my family, estate, heirs, administrators, personal representatives, or assigns, if I am deceased, and shall be deemed as an Assumption of Risk and Release of claims, as to the Above-Named Releasees. I further agree to save and hold harmless, indemnify, and defend Releasees from any claim by my family arising from my participation in this event.

I further agree that this Release shall be construed in accordance with the laws of the State of Michigan without application of any principles of choice of law and venue for disputes arising from my participation in this event, or this Release shall be in Berrien County, Michigan. If any term or provision of this Release shall be held by a court of law illegal, unenforceable, or in conflict with any law governing this Release, the validity of the remaining portions shall not be affected thereby.

I hereby certify that, with or without accommodation, I have no health-related reasons or problems that preclude or restrict my participation in this event. I hereby consent to first aid, emergency medical care, and, if necessary, admission to an accredited hospital for executing such care or treatment for injuries I may sustain while participating in any activity associated with this event.

I state that I am fully competent to sign this Release, that I voluntarily execute this document after carefully reading its terms and with full knowledge of the contents and consequences stated herein, and that my signature has not been obtained under duress or coercion. I acknowledge that prior to signing this Release, I have the right to consult with an advisor or attorney of my choice.

I have read, understand and agree to the condition of this ASSUMPTION OF RISK & RELEASE, and do affirm that I am the person whose name appears in this application and have provided valid and correct information and agree to abide by its contents.

I will be a guest of the host country and subject to the local laws and customs and to Vision Outreach International’s policies.

I will be working under and subject to the authority of the training Ophthalmologist or Project Director and agree to abide by his or her directives while visiting and working in the host country. I will be personally responsible for my transportation, lodging, meals, and other incidental expenses. I understand that should I cancel my participation, any refunds of airfare or other prepaid services will be my responsibility.

I further give Vision Outreach International officers, expedition leaders, and other designated personnel my authorization to release pictures or stories about my participation in an expedition or training to be used in media, promotions, and website

SEND IT TO [email protected]


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Participants who are not 18 years of age or older on the date of signature must sign above, and must obtain the signature of a parent or legal guardian below:

I certify that I am the parent or legal guardian of the above-named participant in this event. On behalf of myself and my spouse, partner, co-guardian, or any other person who claims the participant as a dependent, I have read the above agreement, I understand the contents of this Acknowledgement of Risk and Release, assent to its terms and conditions, and sign this Acknowledgement of Risk and Release of my own free act. I acknowledge that my dependent and I have agreed to the terms and conditions of my dependent's participation in this event, and I hereby give my consent to participation by my dependent in the Program and/or Course, and to receive medical treatment determined to be necessary. I further agree to hold harmless, indemnify and defend the above named Releasees from and against all claims, demands or suits that my dependent has or may have.

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