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2019 Makarios Mandatory Trip Waiver
Every trip member must fill out this form by the deadline. This information is essential to our planning process and helps us keep trip members safe.
GENERAL TRIP INFORMATION
DATE OF TRIP *
FIRST NAME (as seen on Passport) *
Your answer
LAST NAME (as seen on Passport) *
Your answer
DATE OF BIRTH (MM/DD/YYYY) *
MM
/
DD
/
YYYY
GENDER *
DIETARY RESTRICTIONS *
(Please be specific or if not applicable type None)
Your answer
T-SHIRT SIZE *
Are you a Makarios Sponsor? *
If YES, please type the name(s) of the student, staff member, and/or class that you financially support through Makarios sponsorship. (Note: we will make every effort to coordinate a home visit during your trip)
Your answer
BLOOD TYPE *
(Why do we ask for this? In the event of a medical emergency, you may require a blood transfusion. While we no longer require this information, we still highly suggest that you learn and email your blood type before arriving to the DR.)
AGE *
Your answer
PASSPORT EXPIRATION DATE *
MM
/
DD
/
YYYY
PASSPORT ISSUE DATE *
MM
/
DD
/
YYYY
PASSPORT NUMBER/ COUNTRY *
IMPORTANT: Please provide your passport number AND passport country.
Your answer
CONTACT INFORMATION
EMAIL ADDRESS *
Your answer
MAILING ADDRESS (STREET NUMBER and NAME, APT & UNIT NUMBER) *
Your answer
CITY *
Your answer
STATE *
Your answer
ZIP CODE *
Your answer
#1 EMERGENCY CONTACT NAME / RELATIONSHIP TO YOU *
Your answer
#1 EMERGENCY CONTACT PHONE (###) ###-#### / EMAIL *
Your answer
#2 EMERGENCY CONTACT NAME / RELATIONSHIP TO YOU *
Your answer
#2 EMERGENCY CONTACT PHONE (###) ###-#### / EMAIL *
Your answer
MEDICAL HISTORY DETAILS
Please thoroughly fill out this section for our records. In case of emergency, it is important for Makarios to have all of this information.
PSYCHIATRIC HISTORY *
Your answer
SURGICAL HISTORY *
Your answer
OTHER MEDICAL INFORMATION WE NEED TO KNOW?
Your answer
ALLERGIES *
Your answer
MEDICATIONS *
Your answer
MINISTRY TRIP HELPFUL INFORMATION
WHEN WAS YOUR LAST TRIP WITH MAKARIOS? *
DESCRIBE YOUR LEVEL OF SPANISH, IF ANY. *
The goal of our short-term trips is to bless, educate, and encourage our staff and local community. What gifts do you have that could be used to help further this vision in the Dominican Republic during your trip?
To specify from above or to provide another skill, please share here:
Your answer
AGREEMENTS & SIGNATURE
PHOTO RELEASE
I grant to Makarios, the right to take photographs of me and my family in connection with Makarios short-term trips. I authorize Makarios, its assigns and transferees to copyright, use and publish the same in print and/or electronically.
I agree that Makarios may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
By checking the box you agree to the Photo Release terms listed above. *
Required
LIABILITY, VOLUNTEER STATUS, & MEDICAL
MAKARIOS – Short-Term Trip Activities

In consideration of MAKARIOS permitting me to participate in a short-term trip(s) (the “Activities”), I willingly enter into this Release and Waiver of Liability Agreement. The Activities under this Agreement include, but are not limited to:

International Travel (air travel, time in connecting airports, etc.)
Transportation in Dominican Republic (seatbelts will not be available on all vehicles in the country)
Accommodations in the Mak House
Engagement with local community (including interaction with children & adults with various diseases including HIV)
Building Projects
Sports Camps
Large Group Games
Worship Gatherings
Beach Day (swimming, games, activities, etc.)
Other activities to be announced

I agree to the acknowledgments, authorizations, releases, and agreements set forth in this Release and Waiver of Liability Agreement. In entering into this Agreement, I acknowledge that some of the Activities may involve hazardous activities that have inherent risks that could result in injuries or death. I have knowingly and voluntarily chosen to participate in the Activities despite these associated risks and freely assume all such risks, including any risks not known to me or not readily foreseeable at this time and risks arising from the negligent acts or omissions of others.

I, for myself and on behalf of my assigns, representatives, heirs, executors, and administrators, hereby agree as follows:

1. Authority to Seek Medical Care and Transport for Medical Care. I authorize and grant to MAKARIOS the authority, in the event that I am incapacitated and unable to make medical decisions for myself, to seek medical care for me, including, but not limited to, such medical and surgical treatment or procedures as the treating physician chosen by appropriate MAKARIOS personnel may, in such physician's sole determination, deem necessary or advisable. I further authorize and grant to MAKARIOS and the appropriate personnel authority to transport me at their discretion to such medical facilities as they may deem necessary or advisable. I certify that I have adequate insurance to cover any injury or illness I may suffer during the Activities and agree to bear all costs related to such injury or illness, including all medical and surgical costs incurred by MAKARIOS for me upon the advice of the treating physician.

2. RELEASE AND INDEMNIFICATION. I RELEASE, WAIVE, DISCHARGE, INDEMNIFY AND HOLD HARMLESS MAKARIOS, ITS STAFF, OFFICERS, EMPLOYEES, MEMBERS, AND AUTHORIZED VOLUNTEERS (the “Releasees”) FROM ANY AND ALL LIABILITY, LOSS, DAMAGE, OR EXPENSE (INCLUDING, WITHOUT LIMITATION, REASONABLE ATTORNEYS’ FEES AND EXPENSES) AND ANY CLAIM OR DEMANDS FOR THE SAME ON ACCOUNT OF INJURY OR DEATH TO ME OR DAMAGE TO MY PROPERTY ARISING OUT OF OR RELATED TO MY PARTICIPATION IN THE ACTIVITIES; THIS RELEASE, WAIVER, DISCHARGE, INDEMNIFICATION, AND HOLD-HARMLESS APPLIES EVEN IN THE EVENT OF NEGLIGENCE OR FAULT BY THE RELEASEES.

3. Indemnification from Claims by Third Parties. I agree that, if despite this Release and Waiver of Liability Agreement, I or anyone acting on my behalf makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any litigation expenses, attorney’s fees, loss, liability, damage, or cost they may incur as a result of such claim.

4. Complete, General & Unconditional Release. I acknowledge that it is my intention with this instrument to make a complete, general, and unconditional release of any and all claims whatsoever against the Releasees as set forth above. Furthermore, I acknowledge that neither MAKARIOS nor any of the Releasees has made any representations or warranties whatsoever regarding the Activities or the materials or services provided.

5. Media Release. I agree to let the Releasees use my name, picture, portrait, photograph, likeness, and demographic information free of charge in all forms and media or other manner for advertising, publication, or other lawful purpose, and I waive any right to inspect or approve the finished product, including written copy, which may be created in connection with such use. I agree that any such recording may be distributed through any means, including but not limited to fundraisers, DVDs, or the Internet. I release all claims against MAKARIOS with respect to the copyright, publication, or use of these video and audio recordings, photographs, or other visual and audio representations.

I am signing this document on my own behalf and on behalf of my assigns, representatives, heirs, executors, and administrators and I agree to be specifically bound to all terms and conditions of this Agreement. I have read this agreement, fully understand that I am giving up substantial rights by signing it, am aware of its legal consequences, have signed this Agreement freely and voluntarily, and knowingly accept all the terms and conditions as set forth above. I FURTHER ACKNOWLEDGE AND UNDERSTAND THAT MY SIGNATURE BELOW CONSTITUTES A RELEASE OF LIABILITY OF MAKARIOS AND THE RELEASEES. This agreement is intended to be governed by the Uniform Electronic Transactions Act (Tex. Bus. Com. Code, Section 43.001 et seq.) and applicable federal law governing the enforceability of electronic signatures. Your signature on this agreement conveyed electronically is intended to be fully binding for all purposes, and your conveyance of your signature on this agreement to MAKARIOS by any electronic means is your acceptance of these terms.

6. I understand that as I am raising funds, I am doing so voluntarily for the organization. As a volunteer, I am offering my services willingly and I understand that I am in no way an employee of the company, nor am I being led to believe that a paid position will be offered in the future.

As a volunteer, Makarios will provide you with reimbursements for for any reasonable out-of-pocket expenses that you incur when performing authorized tasks associated with with your role. We do this to ensure that you are not financially disadvantaged as a result of your volunteers position with us. These payments are not remunerated of wages. You might need prior approval and will always need to produce receipts.

We may sometimes provide you with other benefits as part of your volunteer role (examples include training, food, accommodation, event entry, clothing, or equipment). Where this occurs, it is on a gratuitous basis at the discretion of Makarios and is not payment in lieu of salary. Makarios will do their best as an organization to train and prepare you for your role, and you will reciprocate my services and timeliness. ​
By checking the box you agree to the terms listed above. *
Required
ELECTRONIC SIGNATURE (FULL NAME REQUIRED) *
SIGNING HERE MEANS YOU HAVE READ, UNDERSTAND, & AGREE TO THE ABOVE INFORMATION.
Your answer
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