| I hereby release VOSH-Connecticut, its mission leaders, officers
and other designated personnel from the responsibility for any accident,
injury, sickness or death to me or any member of my family, and/or
loss or damage to material items occurring before, during, after or
as a result of the mission of January 10 -17, 2004 to San Juan del
Sur, Nicaragua.
I further authorize VOSH-Connecticut and its designees to release
any pictures or stories about my participation in the mission to
any news, radio, TV, website or other media.
I further understand that should it be necessary for me to cancel
out of the mission for any reason, there is no refund of airfare
and any other related charges, costs, fees and assessments. These
are all my responsibility and I understand and agree that VOSH-Connecticut
and its mission leaders will not be responsible in any way for the
refund of said monies.
I hereby state that I am over the age of 18 and qualified and of
legal age and authority to sign this release.
I have read and agree with the terms set forth herein, and I am
signing this release and participating in the mission voluntarily
of my own free act and deed with no expectation of reimbursement
or remuneration of any kind.
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