The information requested is designed to assist Northwest Assembly of God (Northwest AG) in providing for the safety of participants during Northwest AG sponsored activities.
PHOTOGRAPH AND VIDEO RELEASE FORM
I hereby grant Northwest AG permission to the rights of my image, likeness and sound of my voice as recorded on audio or videotape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.
I agree that Northwest AG may use such images of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.
There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.
By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against Northwest AG for utilizing this material.
ASSUMPTION OF RISK, INSURANCE, & MEDICAL TREATMENT
1. I, the aforementioned participant, in consideration of my being permitted to work as a volunteer with Northwest AG, recognize I am not an employee of Northwest AG and represent that I am at least 18 years of age, and I further represent and agree as follows:
2. I am aware of the hazards and risks to my person and property associated with serving in a humanitarian relief capacity, such hazards and risks including, but not being limited to, death or injury by accident, disease, war, terrorists acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence. I accept my assignment with full awareness of these risks, and, subject to the required insurance coverage described below, I voluntarily assume all risks of death, injury, illness, and damage to myself or any member of my family associated with such risks, and any damage to my personal property.
3. I attest and certify that I have no medical conditions that would prevent me from performing my duties.
4. I waive and release any and all claims for damages which I, or my heirs or successors, may have against Northwest AG, or any agent or employee of any of such organizations, arising from my death, injury, or illness, or any property damage or loss occurring during the term of my assignment or as a result of my assignment.
5. In the event that I have minor children who will accompany me on my assignment, I, acting both on my own behalf and in their behalf as their parent and legal guardian, do hereby assume all risks of death, illness, or injury that they may suffer as a result of said assignment, from those causes described above.
6. I understand and accept the following policy of Northwest AG regarding ransom payments: Northwest AG has determined that it will not pay ransom nor yield to the demands of anyone who takes one of our staff or volunteers hostage. Northwest AG pledges itself to every effort and all appropriate means to obtain the release of one taken hostage, should it ever occur. This policy was made after sufficient study of the policies of other institutions and after considering the advice of the United States State Department.
7. I expressly waive any defense to the enforcement of any provisions of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me enforceable against me in accordance with its terms.
8. I hereby release, waive and covenant not to sue, and further agree to indemnify, defend and hold harmless the following event organizers and sponsor, and each of their respective parent, subsidiary and affiliated companies, officers, directors, members, agents, employees and volunteers with respect to any liability, claim(s), demand(s), cause(s) of action, damage(s), loss or expense (including court costs and reasonable attorney’s fees) of any kind or nature ("liability") which may arise out of, result from, or relate to my participation in the activity, including claims for liability caused in whole or in part by the negligence of the event organizers or sponsor. I further agree that if, despite this agreement, i, or anyone on my behalf, makes a claim for liability against any of the event organizers or sponsor, i will indemnify, defend, and hold harmless each of the event organizers and sponsor from any such liability which any may be incurred as the result of such claim.
9. I hereby warrant that I have read this Agreement carefully, understand its terms and conditions, acknowledge that I will be giving up substantial legal rights by signing it (including the rights of the minor, my spouse, children, parents, guardians, heirs and next of kin, and any legal and personal representatives, executors, administrators, successors and assigns), acknowledge that I have signed this Agreement freely and voluntarily, without any inducement, assurance or guarantee, and intend for my signature to serve as confirmation of my complete and unconditional acceptance of the terms, conditions and provisions of this Agreement. This Agreement represents the complete understanding between the parties regarding these issues and no oral representations, statements or inducements have been made apart from this Agreement. If any provision of this Agreement is held to be unlawful, void, or for any reason unenforceable, then that provision shall be deemed severable from this Agreement and shall not affect the validity and enforceability of any remaining provisions.
MEDICAL TREATMENT AUTHORIZATION
In the event that I am medically incapacitated, injured or become ill, I authorize Northwest AG representatives to call a doctor and/or work to provide necessary medical treatment. I authorize any leader participating on this trip or any Northwest AG staff member to make emergency medical care decisions on my behalf, if required by law or a health care provider. I understand the Northwest AG office, and any of their agents, employees, or volunteers, will not be responsible for medical expenses incurred on the basis of this authorization. I agree to notify Northwest AG in the event of any health changes or changes in medicine that would restrict my participation in any activities. I also understand that Northwest AG representatives reserve the right to restrict any activity that they do not feel is within my physical capabilities.