Release Agreement Form

I ,___________________________________, have volunteered to serve on a mission to Haiti organized by the Community Coalition for Haiti, a non-profit organization dedicated to improving medical care, public health, and economic and educational opportunities in Haiti.

I understand that Haiti is one of the least developed and least stable countries in the Western Hemisphere and that it lacks most of the public health and public safety resources of the United States and other Caribbean countries. I understand that my travel to and in Haiti and my participation in the activities of the Community Coalition for Haiti involve a number of significant risks, including the risk of violence, serious injury, illness or death. Prior to signing this Waiver and Release Agreement, I have reviewed and understand the most recent version of the United States Department of State’s Consular Information Sheet regarding Haiti and any Travel Warnings issued for Haiti (available at www.travel.state.gov). I have also reviewed and understand the Center for Disease Control’s Health Information for Travelers to the Caribbean (available at www.cdc.gov/travel). These documents describe some, but not all, of the risks associated with travel in Haiti and my participation in the activities of the Community Coalition for Haiti.

I understand that the Community Coalition for Haiti cannot ensure or guarantee my health or safety. I hereby expressly and specifically assume the risk of any injury, illness or harm arising out of or associated in any way with my voluntary participation in the mission to Haiti and in the activities of the Community Coalition for Haiti.

Acknowledging that such risks exist and that I have assumed all such risks, I hereby release, discharge, indemnify and hold harmless the Community Coalition for Haiti and its officers, directors, employees, representatives, agents, successors, assigns, and volunteers (collectively, “its representatives”), from and against any and all damages, demands, claims, actions, causes of action, suits, expenses, and/or loss or liability of any kind or nature whatsoever (including, without limitation, costs of judgments, settlements, court costs, and attorney’s fees), arising out of, resulting from, or in any manner relating to my participation in the mission to Haiti, the activities of the Community Coalition for Haiti, or the actions, inactions or negligence of the Community Coalition for Haiti or any of its representatives. I recognize, therefore, that if I am hurt, become ill and/or my property is damaged while I am engaged in the mission to Haiti or in the activities of the Community Coalition for Haiti, I will have no right, and I hereby waive the right, to make a claim or file a lawsuit against the Community Coalition for Haiti or any of its representatives, even if such injury or damage was caused by the Community Coalition for Haiti or any of its representatives. . This Waiver and Release shall bind me and my heirs, successors, legal representatives and assigns and inure to the benefit of the Community Coalition for Haiti, its representatives and their respective successors and assigns.

I have read and understand this Waiver and Release Agreement and have signed this voluntarily.

*Signature: ________________________________

Name As It Appears On Passport: _____________________________

Date Form Completed: ___________________

Insurance Beneficiary: ____________________________________

Relationship of Beneficiary to traveler__________________________

Travel Insurance is provided to each participant by Adams & Associates International, www.aaintl.com.