Acknowledgement and Release for Alliance for Smiles mission to Retalhuleu, Guatemala – February 25 to March 5, 2022
Your Name (required)
Your Email (required)
I have voluntarily agreed to participate in an international surgical trip (the “program”) sponsored by Alliance for Smiles, Inc (AfS). I acknowledge that there may be significant potential dangers and risks as a result of the occurrence of events during my participation in the program which might cause personal injury or sickness, death or damage to my own property.
I agree to participate in the program at my own risk, and assume all risks of any kind associated with such participation. I have done any research on the host country that I feel is necessary to allow me to make an informed decision to take part in the program. I understand that on a typical Alliance for Smiles medical mission any of the following may be true:
* Long working hours may be required: at least 10 hours per day, six days per week, with few breaks.
* There is limited climate control.
* Some lifting is required.
* AfS relies on local hosts to provide food and may not have control over the quality of the menu.
* Accommodations are basic with at least two persons to a room. If private rooms are available, a request can be made for a private room but the volunteer will have to pay the additional costs.
* Beds in foreign countries may be very hard.
* Access to prescription drugs may not be available.
* Emergency medical care may not be available for some ailments.
* There is a potential for exposure to blood borne pathogens.
Assumption of COVID-19 Risks
I fully understand and acknowledge that I have made the decision to participate in the Program and provide my services in the midst of the ongoing COVID-19 pandemic voluntarily and with the full understanding of the inherent risks of such decision and acknowledge and agree as follows: (i) COVID-19 is an ongoing extremely contagious worldwide pandemic; (ii) infection with COVID-19 infection can result from close proximity to others, person-to-person contact, exposure to droplets/aerosols released by other volunteers, patients, hospital staff, visitors and others as a result of breathing, coughing, talking and normal interaction as well as by touching surfaces, examining patients and performing surgery; (iii) by participating in the Program, I risk becoming exposed to or infected with COVID-19 as a result of my actions, omissions, or negligence, or those of other AfS volunteers, patients, hospital staff, and others; (iv) contracting COVID-19 can result in personal injury, illness, permanent disability, death, loss of work, and loss of wages; (v) risk increases steadily with age, and persons with underlying medical conditions are considered to be at “high risk” and particularly susceptible to developing severe illness from COVID-19; (vi) AfS cannot guarantee that I will not become infected with COVID-19 during the Program; (vii) participating in the Program could increase my risk of contracting COVID-19; and (viii) AfS is not responsible for the hospital or facility hosting the Program’s COVID-19 mitigation efforts (or lack thereof) or any negligence by such hospital or facility’s or its staff relative to such precautions (collectively, the “COVID Risks”). I hereby assume all of the COVID Risks including all risks of injury or illness, including death, disability, lost wages, or work (including those arising in connection with travel restrictions or quarantine requirements), and damage or loss to myself or my property that might result from the COVID Risks.
I represent and warrant that I will strictly abide by and adhere to all infection prevention and COVID-19 rules and requirements set by Alliance for Smiles, the host hospital/healthcare facility, and the country/region, which may include, without limitation, wearing a face mask at all times, undergoing COVID-19 testing, reporting all potential COVID-19 symptoms and exposure (or potential exposure) to COVID-19 (collectively, the “Covid-19 Protocols”). I understand that failure to adhere to the COVID-19 Protocols may result in the cancellation of my procedures and removal from the Program.
In consideration of AfS’ sponsorship of the program, and its decision to allow me to participate, by clicking SUBMIT below, I hereby waive, release and forever discharge AfS and its employees, agents, directors, sponsors, promoters, and volunteers from any and all liability, claim, damage, loss cost or expense arising from or attributable in any way to any of the events enumerated in the preceding paragraph or any action, omission to act or negligence of any such person or organization in connection with the sponsorship, organization or performance of services associated with the trip, including related travel.
Today's Date (required)