All groups and individuals participating in Appalachian Youth Missions must read this entire disclaimer
understanding fully the terms and conditions. By signing below, you agree to abide by all the terms and
conditions herein stated or implied. A.Y.M must receive this disclaimer signed by each participant and a
copy of current/valid individual or group medical and liability insurance coverage sent before you arrive.
We need to receive this by ground mail only. Medical (personal injury) and liability insurance must be
current and cover each member of the group for the entire time they are on the mission trip while working
under at A.Y.M. Call by phone to see if you qualify for an exemption status on insurance coverage. If you
qualify under the exemption status, you maybe required to sign a an additional disclaimer.
You hereby release, forever discharge and agree to hold harmless The Church under Jesus Christ,
Appalachian Youth Mission/Missions, The Counsel of Elders of Appalachian Youth Mission recognized as
a Tennessee Unincorporated Religious Society, Fishes and Loaves Fellowship, Participants, Property
Owners, Mission Coordinators, Mission Interns, Interns, Coordinators, Volunteers, Sponsors, Donator's or
other bystanders during your stay from all liability, personal injury, sickness or sickness or injury resulting
in death, as well as, property damage and expenses of any nature whatsoever.
I grant/authorize my permission for the individual named/described below should the need arise, to secure
a doctor or hospital and hereby do authorize medical treatment including but not limited to emergency
surgery. I do and will assume all financial responsibility of all medical costs, including transportation.
By signing this form you accept the conditions of a non-electric environment and the use of outhouses or
porta potties in lieu of modern plumbing. A reasonably safe and clean environment will be provided for
sleeping and eating. You agree to maintain these environments in safe, clean and proper condition at all
times. If you have a past or present medical condition which may affect your ability to respond in certain
situations or may cause harm or injury to yourself or others, these conditions must be disclosed to the
mission’s coordinator before arriving or participating in the mission’s experience.
Each individual is responsible to bring : a suitable sleeping bag, small air or foam mattress (not to exceed
30 inches in width), personal hygiene products, long pants only (modest shorts can be worn to bed), one
piece bathing suit, water shoes, towel, work cloths & gloves, work boots, pocket knife, hat, sun glasses
and your Bible are strongly recommended. Please refrain from bringing insect repellent, conditioners,
sunscreen or any other items that may be harmful to the environment here.
You agree to take full responsibility for your actions and not hold liable in any way, shape or form
Appalachian Youth Mission/Missions, The Counsel of Elders of Appalachian Youth Mission recognized as
a Tennessee Unincorporated Religious Society, Fishes and Loaves Fellowship, Participants, Property
Owners, Mission Coordinators, Mission Interns, Interns, Coordinators, Volunteers, Sponsors, Donators or
other bystanders during your stay.
Parent, legal guardian or adult attending please initial here: ________
Your safety is first and foremost to us at A.Y.M so we will ask you not to bring or have in your possession
at any time any drugs, alcohol, drug or alcohol related items of any kind, no candy, cakes, cookies,
snacks, soda, chewing gum,or any product containing sugar or a stimulant-like product or products of any
kind, no perfume or cologne or jewelry of any kind with the exception of wedding bands or any device that
produces sound with the exception of musical instruments, no comic books, toys or electronic games of
any kind or any device or object that would cause a distraction which may lead to an injury or impair an
individual’s ability to respond in a safe and alert way. Your safety is most important to us.
You agree to bring $6.00 per meal amounting to $18 per day per person for your meals. You will be
purchasing and preparing these meals here, being responsible for your own meals. We will coordinate
this together under A.Y.M guidelines. Any and all leftover funds will go directly into mission projects and
materials. Additional leftover food will go directly back into the A.Y.M mission out reach program for
distribution.
You agree to get up early in the morning (this may be before the sun rises). Ordinarily, no paper products
will be used during meals (the mission field does not support these products but In some cases there will
be an exception to this rule due to specific location and scheduling). Each individual will be responsible
for his or her own plate, cup/jar and eating utensils which are provided for you. You agree to keep these in
a clean condition before and after use. Bleach and soap will be used before and after each meal in
washing hands and cleaning. Food preparers will use fingernail brushes and soap before preparing food.
Cave exploration is at your own risk. If you choose this educational activity you do so at your own risk. All
cave exploration participants assume full responsibility for their actions and decisions during and before
entering a cave. All cave exploration participants under the age of 21 must be accompanied during the
exploration by an adult from their group and have parental permission to participate by having their parent
or legal guardian’s signature/printed signiture and telephone number on this line:
________________________________________________________________________________
Jumping from any height into water is strongly prohibited and is done at your own risk.
By signing below you agree to all the terms and conditions stated herein and will follow and comply with all
instructions for your safety and the safety of others while staying here. Your safety is very important to us
and is first and foremost. Do not sign unless you have fully read, understand and agree with the above
disclaimer.
Participant: print full name ________________________________________ Age _______
Address___________________________________________________________________
City, State, Zip______________________________________________________________
Parent or legal guardian please initial here: _______________
Parent or Legal guardian's E-mail address __________________________________________
Parent or legal guardian’s contact # at home, work & cell phone number _____________________
____________________________________________________________________________
Parent or legal guardian: print full name ______________________________________________
Parent or legal guardian, sign full name ______________________________ Date ________
Participant: sign full name ________________________________________ Date ________
STATE OF ____________________, COUNTY OF _____________________:
BEFORE ME, a Notary Public, on this ____ day of _____________, 201__,
___________________________ personally appeared and executed the above Disclaimer, and
acknowledged the same to be his/her free act and deed.
____________________________________
Notary Public, _________________ County, Commission Expires:
understanding fully the terms and conditions. By signing below, you agree to abide by all the terms and
conditions herein stated or implied. A.Y.M must receive this disclaimer signed by each participant and a
copy of current/valid individual or group medical and liability insurance coverage sent before you arrive.
We need to receive this by ground mail only. Medical (personal injury) and liability insurance must be
current and cover each member of the group for the entire time they are on the mission trip while working
under at A.Y.M. Call by phone to see if you qualify for an exemption status on insurance coverage. If you
qualify under the exemption status, you maybe required to sign a an additional disclaimer.
You hereby release, forever discharge and agree to hold harmless The Church under Jesus Christ,
Appalachian Youth Mission/Missions, The Counsel of Elders of Appalachian Youth Mission recognized as
a Tennessee Unincorporated Religious Society, Fishes and Loaves Fellowship, Participants, Property
Owners, Mission Coordinators, Mission Interns, Interns, Coordinators, Volunteers, Sponsors, Donator's or
other bystanders during your stay from all liability, personal injury, sickness or sickness or injury resulting
in death, as well as, property damage and expenses of any nature whatsoever.
I grant/authorize my permission for the individual named/described below should the need arise, to secure
a doctor or hospital and hereby do authorize medical treatment including but not limited to emergency
surgery. I do and will assume all financial responsibility of all medical costs, including transportation.
By signing this form you accept the conditions of a non-electric environment and the use of outhouses or
porta potties in lieu of modern plumbing. A reasonably safe and clean environment will be provided for
sleeping and eating. You agree to maintain these environments in safe, clean and proper condition at all
times. If you have a past or present medical condition which may affect your ability to respond in certain
situations or may cause harm or injury to yourself or others, these conditions must be disclosed to the
mission’s coordinator before arriving or participating in the mission’s experience.
Each individual is responsible to bring : a suitable sleeping bag, small air or foam mattress (not to exceed
30 inches in width), personal hygiene products, long pants only (modest shorts can be worn to bed), one
piece bathing suit, water shoes, towel, work cloths & gloves, work boots, pocket knife, hat, sun glasses
and your Bible are strongly recommended. Please refrain from bringing insect repellent, conditioners,
sunscreen or any other items that may be harmful to the environment here.
You agree to take full responsibility for your actions and not hold liable in any way, shape or form
Appalachian Youth Mission/Missions, The Counsel of Elders of Appalachian Youth Mission recognized as
a Tennessee Unincorporated Religious Society, Fishes and Loaves Fellowship, Participants, Property
Owners, Mission Coordinators, Mission Interns, Interns, Coordinators, Volunteers, Sponsors, Donators or
other bystanders during your stay.
Parent, legal guardian or adult attending please initial here: ________
Your safety is first and foremost to us at A.Y.M so we will ask you not to bring or have in your possession
at any time any drugs, alcohol, drug or alcohol related items of any kind, no candy, cakes, cookies,
snacks, soda, chewing gum,or any product containing sugar or a stimulant-like product or products of any
kind, no perfume or cologne or jewelry of any kind with the exception of wedding bands or any device that
produces sound with the exception of musical instruments, no comic books, toys or electronic games of
any kind or any device or object that would cause a distraction which may lead to an injury or impair an
individual’s ability to respond in a safe and alert way. Your safety is most important to us.
You agree to bring $6.00 per meal amounting to $18 per day per person for your meals. You will be
purchasing and preparing these meals here, being responsible for your own meals. We will coordinate
this together under A.Y.M guidelines. Any and all leftover funds will go directly into mission projects and
materials. Additional leftover food will go directly back into the A.Y.M mission out reach program for
distribution.
You agree to get up early in the morning (this may be before the sun rises). Ordinarily, no paper products
will be used during meals (the mission field does not support these products but In some cases there will
be an exception to this rule due to specific location and scheduling). Each individual will be responsible
for his or her own plate, cup/jar and eating utensils which are provided for you. You agree to keep these in
a clean condition before and after use. Bleach and soap will be used before and after each meal in
washing hands and cleaning. Food preparers will use fingernail brushes and soap before preparing food.
Cave exploration is at your own risk. If you choose this educational activity you do so at your own risk. All
cave exploration participants assume full responsibility for their actions and decisions during and before
entering a cave. All cave exploration participants under the age of 21 must be accompanied during the
exploration by an adult from their group and have parental permission to participate by having their parent
or legal guardian’s signature/printed signiture and telephone number on this line:
________________________________________________________________________________
Jumping from any height into water is strongly prohibited and is done at your own risk.
By signing below you agree to all the terms and conditions stated herein and will follow and comply with all
instructions for your safety and the safety of others while staying here. Your safety is very important to us
and is first and foremost. Do not sign unless you have fully read, understand and agree with the above
disclaimer.
Participant: print full name ________________________________________ Age _______
Address___________________________________________________________________
City, State, Zip______________________________________________________________
Parent or legal guardian please initial here: _______________
Parent or Legal guardian's E-mail address __________________________________________
Parent or legal guardian’s contact # at home, work & cell phone number _____________________
____________________________________________________________________________
Parent or legal guardian: print full name ______________________________________________
Parent or legal guardian, sign full name ______________________________ Date ________
Participant: sign full name ________________________________________ Date ________
STATE OF ____________________, COUNTY OF _____________________:
BEFORE ME, a Notary Public, on this ____ day of _____________, 201__,
___________________________ personally appeared and executed the above Disclaimer, and
acknowledged the same to be his/her free act and deed.
____________________________________
Notary Public, _________________ County, Commission Expires:
| DISCLAIMER NOTICE |
| A.Y.M and its representatives reserve all rights inalienable and otherwise explicitly 1999-2011 |