Missions :: Youth Liability Form (17 Years & Younger)


This Liability Form is a a required part of the Westgate Missions Trip application and should be reviewed and completed by both the Minor Applicant and their Parent/Legal Guardian. 

The digital signatures of the Youth Applicant and Parent/Guardian constitute a binding contract with DOVE Westgate Church and are considered the same as a handwritten signature. 

By signing below, the Youth Applicant and Parent/Guardian are indicating their agreement with the terms and conditions as listed. 

There are four parts to this form requiring signatures. Each section must be completed in its entirety: 

  • Participant Release, Assumption of Risk, & Hold Harmless Agreement (Youth & Parent/Guardian Signature Required) 
  • Parent/Guardian's Additional Release & Indemnification (Parent/Guardian Signature Required) 
  • Consent to Treatment (Parent/Guardian Signature Required) 
  • Consent to Travel (Parent/Guardian Signature Required) 
Only one form per applicant.

If you have any questions, please contact Pastor Wes Dudley, Missions Director, at wesd@dwchurch.org.

***THE NAME OF THE YOUTH APPLICANT*** should be listed below under "Your Name" (NOT THE PARENT'S NAME). Parent/Guardian information will be collected later in the form.

Youth Applicant Information

Please list current address and best number to reach youth below.
Date

Select One Only:

Parent/Guardian Information

Participant Release, Assumption of Risk, & Hold Harmless Agreement


PLEASE REVIEW THOROUGHLY BEFORE SIGNING ::

In consideration of being permitted to participate in this missions trip with DOVE Westgate Church, including travel to and from the mission site (collectively referred to as "DWC Mission Trip Service") and for services of DOVE Westgate Church, their respective agents, employees, trustees, officers, directors, volunteers, sponsors, successors and assigns, and all others acting in any capacity on their behalf to conduct the DWC Mission Trip Service, I AS THE YOUTH APPLICANT, ALONG WITH MY PARENT/LEGAL GUARDIAN, HEREBY AGREE TO RELEASE, DISCHARGE, INDEMNIFY AND HOLD HARMLESS DOVE WESTGATE CHURCH, ON BEHALF OF MYSELF, MY SPOUSE, MY CHILDREN, MY PARENTS, MY HEIRS, ASSIGNS, PERSONAL REPRESENTATIVES AND ESTATE AS FOLLOWS:

1. I/We acknowledge that engaging in this DWC Mission Trip Service entails both known and unknown risks that could result in illness, severe physical and emotional injury, paralysis, death, or damage and/or loss of property. These risks include, but are not limited to: accidents in the course of travel to and from the destination(s), risk of injury or illness commonly associated with construction, recreation or other missionary service activities (including the risk of negligent acts or omissions), risk of damage and/or loss to luggage, weather related incidents, and risks associated with living and working in regions with underdeveloped security, buildings, roads, sanitation, food, water, and health care services and facilities. I/We understand that such risks are inherent to and cannot be eliminated from DWC Mission Trip Service.

2. I/We understand that DWC Mission Trip Service entails travel in countries and regions where there may be a risk of criminal or terrorist activity.

3. I/We acknowledge that my participation in DWC Mission Trip Service is purely voluntary, and I/we expressly agree to accept and assume ALL risks associated with my participation in DWC Mission Trip Service. I/We specifically agree to accept and assume the risk that DOVE Westgate Church may commit negligent acts or omissions during the DWC Mission Trip Service. I/We also agree to accept and assume the risk that any injuries or illness I may suffer during the DWC Mission Trip Service may be made worse by negligent treatment or rescue efforts by DOVE Westgate Church, or other third parties.

4. I/We hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless DOVE Westgate Church, its pastors, its elders, its deacons, its staff members, its volunteers, its congregants, and my DWC Mission Trip Service Team Leader(s), along with DOVE International and DOVE USA and their employees and constituents, from any and all claims, demands, or causes of action, which in any way arise from or are related to my participation in DWC Mission Trip Service, including all claims alleging negligence if I am injured or become ill in any way during DWC Mission Trip Service.

5. In the event that I or any legal representative acting on my behalf files a lawsuit against DOVE Westgate Church, I/we agree to do so solely in the Superior Court of the State of Pennsylvania, County of Lancaster. I/We further agree that Pennsylvania substantive law shall apply without regard to the conflict of law rules of Pennsylvania or any other state or nation. I/We agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

6. I represent that I am under 18 years of age and include my parent/legal guardian's signature below on my behalf. By signing below, my parent/legal guardian represents that they are fully competent to sign this Release of Liability agreement on my behalf. This Release of Liability and Indemnification Agreement shall be binding to the fullest extent permitted by law. If any part of this release is deemed to be unenforceable, the remaining terms shall be enforceable as a contract between parties. This release shall be binding upon my assignees, subrogors, heirs, next to kin, executors and personal representatives.

By signing this document, I (as the Minor Applicant) and my Parent/Legal Guardian acknowledge that I/we may be found by a court of law to have waived my/our right to maintain a lawsuit against DOVE Westgate Church, including claims that DOVE Westgate Church has committed negligent acts or omissions. I/we have had a sufficient opportunity to read this entire document. I/We have read and understood it, and agree to be bound by its terms.

By checking this box, the Youth Applicant and Parent/Guardian affirm that they have read, understand, and agree to be bound by these terms, as stated above.

As further indication of Youth Applicant's agreement, please sign below by printing your FULL NAME, as listed on your passport. Please note :: Your digital signature constitutes a binding contract with DOVE Westgate Church and is considered the same as your handwritten signature.

As further indication of the Parent/Guardian's agreement, please sign below by printing your FULL NAME. Please note :: Your digital signature constitutes a binding contract with DOVE Westgate Church and is considered the same as your handwritten signature.

Parent/Guardian Additional Release & Indemnification


In consideration of the Youth Applicant being permitted by DOVE Westgate Church to participate in DWC Mission Trip Service, I have read and understand the foregoing "Participant Release, Assumption of Risk, and Hold Harmless Agreement" and agree that its terms and provisions govern this Parent or Guardian's Additional Release & Indemnification.

In regards to BOTH (1) Youth's personal rights and (2) the personal rights of Youth's parents or guardians, I agree to accept and assume ALL of the risks to Youth Applicant, arising from or related to Youth's participation in DWC Mission Trip Service, including the risk that DOVE Westgate Church may commit negligent acts or omissions, and the risk that any injury or illnesses Youth experiences may be made worse by negligent treatment or rescue efforts by DOVE Westgate Church or other third parties.

I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless DOVE Westgate Church, its pastors, its elders, its deacons, its staff members, its volunteers, its congregants, and the DWC Mission Trip Service Team Leader(s) from any and all claims, demands, or causes of action, which in any way arise from or are related to Youth's participation in DWC Mission Trip Service, including all claims alleging negligence, and including negligence concerning treatment or rescue efforts, if Youth is injured in any way during the DWC Mission Trip Service.

By checking this box, the Parent/Guardian of the Youth Applicant affirm(s) that they have read, understand, and agree to be bound by these terms, as stated above.

As further indication of your agreement, please sign below by printing your FULL NAME. Please note :: Your digital signature constitutes a binding contract with DOVE Westgate Church and is considered the same as your handwritten signature.

Consent to Treatment


As the Parent/Legal Guardian of the Youth Applicant, I do hereby authorize DOVE Westgate Church, acting as my son's/daughter’s agent, to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis, or treatment including, but not limited to, over the counter medication and hospital care or service, which is deemed advisable and is rendered under the general or specific supervision of any licensed physician and surgeon, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being rendered, but is given to provide authority and power on the part of DOVE Westgate Church to give specific consent to any and all such diagnosis, treatment, or hospital care which the above mentioned physician, in the exercise of his/her best judgment, may deem advisable.

I hereby authorize any hospital which has provided treatment to my son/daughter to surrender physical custody of my son/daughter to DOVE Westgate Church upon completion of treatment.

These authorizations shall remain effective from the start of the DWC Mission Trip Service through its completion and arrival back to DOVE Westgate Church property, unless sooner revoked in writing and delivered to DOVE Westgate Church.

By checking this box, the Parent/Guardian of the Youth Applicant affirm(s) that they have read, understand, and agree to be bound by these terms, as stated above.

As further indication of your agreement, please sign below by printing your FULL NAME. Please note :: Your digital signature constitutes a binding contract with DOVE Westgate Church and is considered the same as your handwritten signature.

Consent to Travel


The Parent/Guardian of the Youth Applicant has entrusted the Youth Applicant into the care of DOVE Westgate Church and its agents, as duly authorized representatives of DOVE Westgate Church, for the duration of the Youth Applicant's participation in this DWC Mission Trip Service and other activities of DOVE Westgate Church. The Parent/Guardian does hereby authorize the Youth Applicant to travel from DOVE Westgate Church to the above-selected mission site location.

By checking this box, the Parent/Guardian of the Youth Applicant affirm(s) that they have read, understand, and agree to be bound by these terms, as stated above.

As further indication of your agreement, please sign below by printing your FULL NAME. Please note :: Your digital signature constitutes a binding contract with DOVE Westgate Church and is considered the same as your handwritten signature.

Date

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