PARTICIPATION FORMS

Name *

First Name

Last Name

Gender *

Male

Female

DO YOU AGREE TO THE FOLLOWING STATEMENT?
I plan to serve with Prosperity Homes in a service mission and related activities sponsored by Prosperity Homes, Visions Made Viable and their partners. (“partner/partners”). I recognize that the participation in such activities may be hazardous and dangerous. *

Yes

No

DO YOU AGREE TO THE FOLLOWING STATEMENT?
In consideration of the privilege of participation extended to me by Prosperity Homes and its partners, through its officers, agents, servants and employees, I do hereby, for myself, my heirs, executor and/or administrator, remise, release and discharge Prosperity Homes and its partners, its officers, directors, principals, agents, servants, employees, heirs, administrators and assigns and/or representatives, from any and all claims, demands, causes of action or liabilities, specifically including claims, demands, causes of action or liabilities arising out of any negligent act by Prosperity Homes or its partners, its officers, directors, principals, agents or servants resulting directly or indirectly in injury, damage, loss or death, to my person or property (including property damage to any of my belongings) which may occur from any cause including, but not limited to serving individually or with others in the Prosperity Homes or related activities sponsored by Prosperity Homes. *

Yes

No

DO YOU AGREE TO THE FOLLOWING STATEMENT?
I understand that by signing this Release of Liability, I expressly and willingly agree to assume complete responsibility for any risk of injury of death that may arise from serving with the PROSPERITY HOMES SERVICE TRIP or related activities sponsored by PROSPERITY HOMES. On behalf of my heirs, assigns and next of kin, and myself I waive all claims for damages, injury or death sustained by my property or me. If I am injured from serving with PROSPERITY HOMES or related activities sponsored by PROSPERITY HOMES I will not hold PROSPERITY HOMES, its officers, directors, principals, agents, servants, employees, heirs, administrators, assigns and/or representatives responsible even if the injuries were caused by negligence on my part or that of PROSPERITY HOMES or any other party or partner under or affiliated with PROSPERITY HOMES. *

Yes

No

DO YOU AGREE TO THE FOLLOWING STATEMENT?
I do not have any physical, medical or mental limitation, ailments or disabilities that would limit or prevent me from serve with the PROSPERITY HOMES, related activities sponsored by PROSPERITY HOMES or that would void Release of Liability *

Yes

No

I HAVE READ AND FULLY AGREE TO THE TERMS OF THIS RELEASE OF LIABILITY. I UNDERSTAND AND CONFIRM THAT BY SIGNING THIS RELEASE OF LIABILITY I HAVE GIVEN UP POSSIBLE FUTURE LEGAL RIGHTS. I HAVE SIGNED THIS RELEASE OF LIABILITY FREELY, VOLUNTARILY AND UNDER NO DURESS OR INDUCEMENT, PROMISE. *

Yes

No

Date *

MM

DD

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