Participation Form

Bethel, Alaska
August 11-19, 2023

Who You Are

Merge Design Payee
For church or school who are not going on a Merge trip but is paying the Merge deposit.
Merge Design Participant
Individual or team leader who goes with a church or school team. Church or school pays Merge directly.

Name

Address

Phone Number

What is the best way to contact you?

Phone
Text
Email

Emergency Contact Name

Emergency Contact Phone Number

Passport Information

If your trip is going out of the country, please upload a copy of your passport information page. If you are in the process of renewing your passport, check box and add date of when you will receive passport. Once received, you will need to email a current copy of your passport page to [email protected].

Passport

Passport Information Page

Browse

Passport Renewal

Holds Harmless and Indemity Agreement

I, in the city of

state of

shall be traveling with The Evangelical Covenant Church and/or Merge

from date and year

to date and year

for the purpose of

hereafter referred to as the Activity.

I understand and agree that neither the Evangelical Covenant Church, Merge, nor its trustees, representatives, employees, and agents may be held liable in any way for an occurrence in connection with the Activity which may result in injury, harm (including death), or other damages to the person or property of the undersigned or members of our organization and guests, including minors, invited or not. Rather, I agree that our Organization alone shall be responsible for any property damage, personal injury or death that may occur during our travels.

As part of the consideration for participating in the Activity,

release the Evangelical Covenant Church, Merge, its trustees, employees, agents, offices of and representatives from any claim for damages, injury, death, or loss of any kind, which may occur while participating in the Activity.

further agree to save and hold harmless the Evangelical Covenant Church, Merge, its trustees, employees, agents, or representatives from any claim arising out of or participation in any form or fashion in the Activity. This agreement shall be binding on my relatives, personal representatives, heirs, beneficiaries, next of kin, or assigns and shall inure to the benefit of the Church and its successors, employees, agents, officers, and assigns.

I understand that in the unlikely event of the fatality of a mission trip participant during the trip, the Evangelical Covenant Church, the local international church, the sending church/organization and the US Department of State will be involved in working to have the remains returned to the USA or Canada as quickly as possible. In extremely rare circumstances this may not occur due to various reasons. I, or any of my relatives, will not hold the Evangelical Covenant Church liable if remains are not returned.

The Evangelical Covenant Church is headquartered in the State of Illinois, and in order to provide certainty in the law to be applied to the construction of their agreement, this agreement shall be governed, construed, and enforced in accordance with the law of the State of Illinois.

I understand the terms of this agreement are contractual and not mere recital; and that I have signed this document of my own free act and volition. I further state and acknowledge that I have fully informed myself of the content of this agreement and release by reading it before I signed it.

I have executed this Hold Harmless and Indemnity Agreement

Partcipant Signature

I, the undersigned, agree to the terms above.

Witness Signature

I, the undersigned, agree to the terms above.

Parent or Guardian

For participants under 18 years old

Volunteer Release

If you are volunteering to serve, you should be aware of risks, be cautious and use good safety procedures.

Some of the areas volunteers might visit may have unusually high risks of unsanitary food or water, disease, civil disturbances or crime. There are dangers inherent in travel and in construction projects. Be a good steward of your life and health. Find out what the risks are and be prepared to meet them. Participants, churches and agencies should talk directly about risks and precautions and not rely on Merge for advice.

Persons volunteering to serve in various programs are not employees or contractors. Therefore, they are not covered by any Worker’s Compensation Insurance or accident or group health or life insurance supplied by the church or agency they are serving. You should obtain any insurance you need. If traveling outside your country, you should check to make certain that you have appropriate medical insurance coverage in effect outside your country.

I acknowledge that I am a volunteer and not an employee or contractor.

I have a responsibility to obtain my own insurance, if needed.

I also have a responsibility to find out about potential risks and take necessary precautions.

I release Serve Globally and any church that is sending or supporting me, the church or agency I am serving, and their employees and agents, of any liability for any injury to me in my volunteer work.

Participant Signature

I, the undersigned, agree to the terms above.

Name

Parent or Guardian

On behalf of my minor child, whom I am responsible,

Medical Insurance Coverage

Current Policy

Team Member

Insurance Company

Company Address

Company Phone Number

Name of Insured and Relationship to Insured

Policy Number

Please check one box below:

I have checked with my insurance company and my current health insurance does cover the trip.

I have checked with my insurance company and my current health insurance does not cover the trip.

If your insurance does not cover your trip, you can purchase travel insurance for coverage during the time away.