The undersigned represents to Thousand Hills Ministry (herein referred to as “THM”), a religious, non-profit corporation, that he/she is the natural parent or the legal guardian of the above named participant or that he/she is the above named participant and is at least 18 years old at time of signing.


  1. As a condition of being permitted to travel with the THM on, and participate in, a mission trip to Haiti, during the above trip dates; the undersigned hereby:
  2. Agrees to assume all normal and foreseeable risks associated with travel to, from and within Haiti (including but not limited to natural disasters, terrorism, political unrest, and contraction of illness) and releases THM and its affiliates from any responsibility for such risks;
  3. Acknowledges that the carriers, hotels and other suppliers (the “suppliers”) providing services in connection with the missions trip are independent contractors and are not agents, employees or representatives of, or joint venturers with, THM or its affiliates and releases THM and its affiliates from any responsibility for the actions or omissions of such suppliers;
  4. Agrees that THM shall have no liability for any personal injury, property damage or other loss, accident, delay, inconvenience, or irregularity which may be caused by (a) any wrongful, negligent or unauthorized acts or omissions on the part of any of the suppliers or their agents, (b) any defect in or failure of any vehicle, equipment or instrument owned, operated or otherwise used by any supplier, or (c) any wrongful or negligent acts or omissions on the part of any other party not under the control of THM;
  5. Releases THM, its officers, directors, employees, agents and representatives from any claims whatsoever relating to the missions trip to Haiti;
  6. Agrees not to sue or otherwise hold THM responsible for any injury, damage, or loss resulting to the undersigned or the undersigned’s property in connection with the undersigned’s participation in the mission trip to Haiti;
  7. Accepts full responsibility for luggage and other belongings brought on the mission trip by the undersigned;
  8. Agrees to submit any dispute, claim or cause of action arising out of the undersigned’s participation in the missions trip to Haiti solely to a Christian arbitration panel, agreeing that lawsuits among and between Christians is prohibited by Scripture; and
  9. Agrees to be responsible for any injuries, damages or losses caused by the undersigned while the undersigned is traveling with representatives of THM or while the undersigned is in Haiti.
  10. The undersigned acknowledges that he/she has been informed that United States citizens traveling outside of the United States are required to carry documentation of United States citizenship, which may include a valid passport or notarized copy of the citizen’s birth certificate with a raised seal, and a valid picture I.D. (such as a driver’s license).


  1. The undersigned acknowledges that THM has recommended that the undersigned obtain a physical examination and proper inoculations prior to going on the mission trip.
  2. The undersigned does hereby consent to such participant taking part in noted activity, with full understanding that insofar as such activity will involve missions, sporting activity, mingling with other individuals and groups; that there is always the risk of injury, illness, loss and possible consequent expense for medical, diagnostic and curative treatments, and incidental loss and expense, and the undersigned does for him/herself and for and on behalf of such participant assume the risk of such an expense.
  3. The undersigned agrees to abide by the rules and regulations, supervision and discipline set and applied by THM and its agents, and does hereby authorize THM or its staff members or other agents to arrange for and consent to X-ray examinations, anesthetic, dental, medical, or surgical diagnosis, and treatment, and hold harmless THM from any such. The undersigned will furnish payment or insurance for any such payment, at his/her own expense.



  1. The undersigned gives THM and its agents permission to take and use photos, videos, stories, or any other recording of such participant or such participant’s likeness for promotional or other purposes. Furthermore, in the event that such participant should be sent home earlier or later than planned and/or by way of transportation other than that which was planned due to reasons including, but not limited to, illness, injury, or failure to comply with THM rules and policies, the undersigned agrees to take responsibility for any and all additional expenses, arrangements, and inconveniences necessitated by such action, and the undersigned agrees to release THM and its agents from all expense and liability, whether financial or otherwise.