VOSH RELEASE and WAIVER FORM

VOSH RELEASE and WAIVER FORM

The undersigned affirms, understands, and agrees that Volunteer Optometric
Services to Humanity (“VOSH”) and the mission leaders are volunteering
their efforts to coordinate arrangements to benefit the mission, including
travel, lodging, and meals (if included), among other things, during the work
trip.

In consideration for being allowed to accompany and participate in this
mission, I hereby personally assume all risks in connection with this
mission and I further release VOSH and the mission leaders from all claims,
demands, and actions and for any harm, injury, or damage which my befall
me while on the mission, including all risks in connection therewith, whether
foreseen or unforeseen, and further I agree to save and hold harmless VOSH
and the mission leaders, its representatives, heirs, or assigns, arising out of
my participation in this mission. VOSH and the mission leaders will be held
harmless for any occurrence in connection with or operation thereof, which
may result in injury, death, or other damage to me or my family, heirs, or
assigns. Further, VOSH and the mission leaders will not be held responsible
for loss of or damage to any equipment, luggage, or personal property taken
on the mission.

I further state that I am of lawful age and legally competent to sign this
affirmation and release; that I understand the terms herein are contractual
and not a mere recital; and, that I have signed this as my own free act. If
I am a minor, then my parents and/or authorized guardian are signing this
agreement on my behalf.

CHAPTER: _____________________________________________

MISSION: _______________________________________________

DATE: __________________________________________________

SIGNATURE OF APPLICANT: _________________________________

IF APPLICANT IS A MINOR, SIGNATURE OF APPLICANT’S PARENTS OR AUTHORIZED GUARDIAN: _________________________________