Pure Water for the World, Inc.

Honduras Trip Form: Release and Waiver

As a condition of being able to go on the trip identified herein,

please complete and return this Release and Waiver to:

Pure Water for the World, Inc., PO Box 55, Rutland, VT 05702

Name:

Address:

City: State: Zip Code:

Phone: Home: Cell: Work:

Email:

Destination(s):

In Case of Emergency Call: Name: Phone:

RELEASE AND WAIVER

Release and Waiver executed by ,

herein referred to as Releasor, on this day of , 20 ,

to Pure Water for the World, Inc., of Rutland, Vermont, herein referred to as Releasee.

The trip to which this Release shall apply is scheduled to occur between , 20 and , 20 and is a trip from the USA to Honduras in order to support the work of Pure Water for the World, Inc. (hereinafter the Trip).

I acknowledge that I am aware that Honduras can be a dangerous place and that there are risks associated with going on the Trip.

I, being of lawful age, in consideration for being able to participate in a Trip to Honduras where I will learn about and see various locations where water purifications systems and sanitation systems have been installed, water filters are or may be manufactured, and participating in other activities to learn about the people of Honduras, do, for myself, my heirs, my executors, administrators, and assigns, hereby release and forever discharge Pure Water for the World, Inc., its employees and directors, successors, and assigns, from any and every claim, demand, action or right of action, of whatever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injury, known or unknown, debt or property damage that may occur at any time during my participation in the Trip and any activities in connection therewith, whether by negligence or otherwise, caused by anyone involved with the Releasee in anyway. This release relates to any risks whether foreseen or unforeseen.

I further release any and all individuals associated with Releasee from any claim whatsoever on account of first aid, treatment, or service rendered during the Trip.

I waive any right, claim, demand that might or could arise from any activity in which I participate while on the Trip.

I understand and agree that Releasee, its employees and directors, may not be held liable in any way for any occurrence in connection with my participation in the Trip. I further agree to save and hold harmless Releasee, its agents, employees, and directors, from any claim by me or my family, estate, heirs, assigns or executors, arising out of my participation in this Trip.

Photo and video release

Photos and video taken by Pure Water for the World, Inc. staff and volunteers are for publicity and/or educational purposes. I waive all rights to my image on any photos or videos or such other photographs or electronic matter (hereinafter collectively “Photographic Material”), understanding that Pure Water for the World, Inc will use the Photographic Material as it deems appropriate, including, but not limited to, the following purposes: marketing/advertising, illustration, print media, Web content, and media yet to be created. I understand that all Photograph Materials will remain the property of Pure Water for the World, Inc, and I am not entitled to any compensation or payment for their use of my image. Additionally, if I provide any Photographic Material to Pure Water for the World, Inc after my trip, unless stated otherwise when I provide the Photographic Material to Pure Water for the World, Inc, I waive any rights to the Photographic Material and Pure Water for the World, Inc may use the Photographic Material as it deems appropriate without obtaining any further authorization or release.

This Release contains the entire agreement between the parties relating to the Release.

Releasor further states that he/she has carefully read the Release and understands the Release and signs it as his/her own free act and deed.

Electronic Signature Date

By entering my name and forwarding this document by email, I acknowledge that this document will be deemed duly executed and enforceable.