COAR Peace Mission * 4395 Rocky River Drive * Cleveland, Ohio 44135-2569 * (216) 252-5572 * coarpm@sbcglobal.net

 
COAR Release Form for visitors to the
COAR Children's Village in Zaragoza, El Salvador
Form date: March 21, 2007
Instructions:
Print, sign (or have your parent or guardian sign) the completed release form and mail it to COAR in Cleveland:
 
COAR Peace Mission
4395 Rocky River Dr.
Cleveland, OH 44135
If any required information is left blank, or if you cannot answer “yes” to any terms of the release information, you may be ineligible to travel to COAR. Please discuss any problems or questions with your group leader.

1. Your Personal Information
* required
Name: *
________________________________________________________________________
Passport number: *
______________________________________ Country: _________________________
Address Line 1: *
________________________________________________________________________
Address Line 2:
________________________________________________________________________
City, State, Zip: *
________________________________________________________________________
* one of these phone numbers is required:  
Work/day Phone: *
________________________________________________________________________
Home/evening Phone: *
________________________________________________________________________
Cell Phone: *
________________________________________________________________________
Fax:
________________________________________________________________________
E-mail:
________________________________________________________________________
Travel Dates : *
________________________________________________________________________
Group or organization: *
________________________________________________________________________
Group leader : *
________________________________________________________________________

2. Emergency Contact Information
* required
Emergency Contact Full Name: *
________________________________________________________________________
Relationship to you: *
________________________________________________________________________
Work/day Phone: *
________________________________________________________________________
Home/evening Phone: *
________________________________________________________________________
Cell Phone:
________________________________________________________________________
E-mail:
________________________________________________________________________
Additional information:
________________________________________________________________________
 


________________________________________________________________________
 
________________________________________________________________________

3. Medical Information
* required
Travel Insurance Company name: * ____________________________________________________
Travel Insurance policy number: * ____________________________________________________
Travel Insurance contact phone number: * ____________________________________________________
Medical Insurance Company Name:
_____________________________________________________
Policy Number:
_____________________________________________________
Emergency Authorization Phone Number:
_____________________________________________________
Primary Care Physician Name:
_____________________________________________________
Primary Care Physician Phone Number:
_____________________________________________________

4. Release Information
* required
Yes
No
 Place a check mark in either the Yes or No box for each item*
    I voluntarily join the trip to El Salvador, named above. In that capacity, I will be traveling to El Salvador, volunteering at COAR Children's Village and visiting pertinent sites.
    I grant to COAR Peace Mission, COAR Children's Village, and the Sisters of Charity of the Incarnate Word, Houston, TX (CCVI), its representatives and employees the right to take photographs or videos of me and my property in connection with my visit to COAR, including preparation for the trip, while in El Salvador, and events afterward and further authorize them and their assigns and transferees to copyright, use, and publish the same in print and/or electronically.
    I agree that COAR Peace Mission, COAR Children's Village, and the Sisters of Charity of the Incarnate Word, Houston , TX (CCVI), may use such photographs and videos of me without my name for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
    I grant to COAR Peace Mission, COAR Children's Village, and the Sisters of Charity of the Incarnate Word, Houston, TX (CCVI), its representatives and employees the right to use any photos or videos that I take and give to them for any purpose such as publicity, illustration, advertising, and Web content, with or without attribution.
    I recognize and assume all risks of travel to, from, and within El Salvador, a country with extreme poverty and crime and often very difficult conditions.
    On behalf of myself, my family, heirs, representatives, executors, administrators and all other persons making any claim by any reason of any relationship to me, I hereby release and hold harmless COAR Peace Mission, The Sisters of Charity of the Incarnate Word – Houston, TX, COAR Children's Village, and any of their affiliates, subdivisions, officers, directors, trustees, teachers, employees, advisors, agents and representatives from any claims, damages, costs, including attorney fees, or other liabilities resulting from personal injury, property damage, or other losses of any kind in any way connected with participation in this program.
    I understand that sponsoring organizations take no responsibility for my medical care or the availability of medical services during this trip.
    I understand that if my behavior endangers the children or staff of COAR or my group I may be asked to leave COAR and El Salvador at my own expense.

I have carefully reviewed the foregoing and this form in its entirety, and by signing below agree to its
terms with full understanding of its meaning and effect.


Signature of participant: _______________________________________ Date: _________


Signature of parent or guardian : ________________________________ Date: _________

Parent or Guardian Information:

Print name of parent or guardian: ________________________________________________


Address, Street, City, Zip: ______________________________________________________


Phone numbers: _____________________________________________________________


E-mail or other contact information: ______________________________________________

 
 
Return signed original to:
COAR Peace Mission
4395 Rocky River Dr.
Cleveland, OH 44135