Pure Water for the World, Inc.

Haiti Trip Form: Release and Waiver For a Minor

As a condition of the minor identified below 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:

In Case of Emergency Call: Name: Phone:

RELEASE AND WAIVER

The Trip to which this Release shall apply is scheduled to occur between ___ 20__ and 20__ and is a Trip from the USA to Haiti in order to support the work of Pure Water for the World, Inc. (herein the Trip). This Release and Waiver is executed by ____ (mother) and

______(father), hereinafter collectively referred to as Releasor for their minor child ______to participate in the Trip. The Release and Waiver is to Pure Water for the World, Inc., of Rutland, Vermont, herein referred to as Releasee.

We acknowledge that we are aware that Haiti can be a dangerous place and that there are risks associated with going on the Trip.

We, being of lawful age, in consideration for our minor child being able to participate in the Trip to Haiti where our child 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 Haiti, do, for our child and ourselves, our heirs, executors, administrators, and assigns, hereby release and forever discharge Releasee, 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 our child’s 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 and Waiver relate to any risks whether foreseen or unforeseen.

We 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 to our child.

We waive any right, claim, demand that might or could arise from any activity in which our child participates while on the Trip whether for our child or ourselves.

We understand and agree that Releasee, its employees and directors, may not be held liable in any way for any occurrence in connection with our child’s participation in the Trip. We further agree for our child and for ourselves to save and hold harmless Releasee, its agents, employees, and directors, from any claim by our child or ourselves or our family, estate, heirs, assigns or executors, arising out of our child’s 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. We waive all rights to our child’s 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. We understand that all Photograph Materials will remain the property of Pure Water for the World, Inc, and we and our child are not entitled to any compensation or payment for their use of our child’s image. Additionally, if we provide any Photographic Material to Pure Water for the World, Inc after our child’s trip, unless stated otherwise when we provide the Photographic Material to Pure Water for the World, Inc, we waive any rights for our child or ourselves 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 and Waiver contains the entire agreement between the parties relating to the Release and Waiver.

Releasor further states that they have carefully read the Release and Waiver and understand the Release and sign it as their own free act and deed and for their child.

______

______

Signatures Date

By entering our name and forwarding this document by email we acknowledge that this document will be deemed duly executed and enforceable.

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