Liability Release Form


use printable version only for signature

Liability Release

Kenyan Urithi Education Fund

The undersigned releases and agrees to hold harmless the Kenyan Urithi Education Fund, Inc.,  a 501(c)(3) nonprofit agency based in Ann Arbor, Michigan, or any employee, officer, director, trustee, or agent, from any liability, injury, damages, loss, accidents, delay, or irregularity related to the undersigned individual’s planned participation or involvement in the _______________, _______ (date) Kenya Service Trip and/or Optional Extensions. 

The undersigned has been advised and understands that the project may involve risks to participants that travel to a developing country like Kenya.

The undersigned agrees to assume all financial responsibility for travel, living and personal expenses associated with this trip whether they are planned or unanticipated expenses.

This release covers all rights and actions of every kind, nature, and description, which the undersigned ever had, now has, or but for this release, may have.  This release binds the undersigned and his or her heirs, representatives, and assignees. 


_______________________________________________   Date:____________

Participant’s Signature                                 

_______________________________________________   Date:  ___________

(1)  Parent signature (if participant is minor) 


Notarization of Liability Release Form

STATE OF _____________________________  COUNTY OF ___________________________

On this ____ day of ___________________, ______(year), before me personally appeared, ______________________, known to be the same person described in and who executed the within instrument, and who acknowledged the same to be the free act and deed thereof.

__________________________, Notary Public

Acting in ______________ County

My commission expires:  ______________

INSTRUCTIONS:  Return form to your Project Leader or Beth Miller, Executive Director at least one month prior to your departure.

Gary McClusky,
Jun 27, 2012, 1:34 PM