Get Involved

Date of Travel

HUMANITARIAN AID MISSION TO HAITI CONSENT AND RELEASE FORM

For and in consideration of being allowed to participate in the delivery of humanitarian
aid in Cabaret-Ville and other regions in Haiti, I hereby agree:

That I will provide true and accurate information as follows:

Your Name (required)

Gender

Contact Phone

Your Email (required)

Date of Birth

Work / Home Address

License #, State, Expiration Date

Specialty

AdultPediatric

Current employer name and contact information

Emergency Contact:

Name

Contact Phone

Email

Work / Home Address

I do hereby release and hold harmless the group “Voice of Cabaret for Health Education
and Infrastructure (VOCHEI)”, its Officers, Directors, agents, and any other participants
or affiliates in the Haiti Mission (collectively, the “Releases”), from and against any and
all liabilities to me and my dependents, assigns, personal representatives, heirs and next
of kin for any and all damages, expenses (including attorney fees), claims, judgments,
actions or causes of action as a result of any loss or injury to my person or property,
including death, which I may sustain or suffer during or arising out of the activities of the
above-described event and during transportation to and from such event.

I do hereby agree to assume all risks and responsibilities surrounding my participation in
this event, including but not limited to any and all foreseen, unforeseen, known, or
unknown risks to my health, safety, or professional status. I acknowledge that I have
obtained whatever information I deemed necessary regarding any risks and have taken whatever steps in my sole judgment and discretion I have deemed appropriate to protect
against such risks. In so doing, I have not relied upon and otherwise disclaim any advice,
information, representations or warranties by the Releases.

I verify that I have any and all professional licenses necessary to provide professional
care and treatment and that those licenses are valid, clear, and active.

I verify that I have no criminal charges or convictions or other criminal or regulatory
disciplinary actions, either final or pending.

I verify that I have no health conditions of which I am aware that would prevent me from
providing services at the mobile clinic or from travel to Haiti.

I verify that I am aware of any and all applicable travel requirements, restrictions, and
warnings; have taken whatever precautions I have deemed necessary for my personal
health and safety; and that I have in my possession valid travel documents and am
otherwise authorized to travel out of the country and to provide aid services in Haiti.

I acknowledge and agree that I am participating in this mission voluntarily and based
upon a full and express assumption of all risks of loss, either to me personally or from
claims of third parties; that I will not seek to recover from the Releases for any harm to
myself or to others for which I may be liable; and that to the extent I deem it appropriate I
have through self-insurance, insurance or otherwise, provided for protection against such
risks.

I further acknowledge that I have read and understand this release and voluntarily sign
this document.

I hereby state, under penalty of perjury, that all the information I provide on this
application is true, complete, and accurate.

Printed Name / E-Signature

Date

Δ

Your Name (required)

Your Address

Profession

Your Email (required)

Your Phone

Please indicate area of interest
Health/Mission TripEducationFundraisingGrant WritingInfrastructure

Would you like to sponsor a child?
YesNo

If yes click Here!!!

Δ

Your Name (required)

Your Address

Profession

Your Email (required)

Your Phone

Please indicate area of interest
Health/Mission TripEducationFundraisingGrant WritingInfrastructure

Would you like to sponsor a child?
YesNo

If yes click Here!!!

Δ