Permission Statement

I, (name of father/mother/guardian) _________________________________________ give authorization for my son/daughter (Participant) ____________________________ to travel with the Kadena Chapel to _______________________________ (location) for ________________________________________________________ (Field Trip event/activity) on _________________________ (date).

Release of Liability/Hold Harmless Agreement

--Please Read Carefully Before Signing--

1. This release of liability agreement must be signed by a parent or authorized caregiver of a children (hereinafter referred to as Parent) before the child (hereinafter referred to as Participant) may participate in the above-mentioned field-trip event/activity (hereinafter Field Trip) with the 18th Wing Chapel (18 WG/HC), Kadena Air Base, Japan.

2. The Parent, in consideration of permission granted by the United States Air Force for the child to participate in an 18 WG/HC field trip, acknowledges and agrees as follows:

a. That participating in a Field Trip may entail risks, both known and unknown, of death or serious injury. The risks may arise from car accidents, slip-and-falls, bad weather, animal bites or other animal-related injuries, water hazards, and rock climbing, among other things. The United States Air Force, by and through its personnel, will strive to protect Participants’ physical safety, but cannot guarantee such safety. This release is intended to cover all injuries of every name, type, kind or nature which the Participant might sustain or suffer from any cause whatsoever connected with or arising out of or by reason of the Participant’s participation in an 18 WG/HC field trip. Other Field Trip-specific risks include:

____________________________________________________________________________

b. That the Participant shall abide by directions given by applicable military regulations, policy directives, instructions, or other applicable guidance to include local supplements, directives, and orders, which are hereby incorporated into this Agreement as if set forth in full within. The Parent/Participant is on notice that such military regulations, directives, instructions, and orders exist, and has a duty to inquire if questions arise as to the content or effect of such directives, regulations, instructions, or orders.

c. The parent believes that the Participant is in good physical condition and health, and there are no medical symptoms, conditions, illnesses, or other ailments which would be aggravated, worsened, or in any way adversely affected by participating in this Field Trip.

3. The Parent releases forever the United States, its agencies, and United States personnel, from every liability arising out of participating in the above-mentioned Field Trip. The Parent will defend, pay or settle every claim or suit against the United States, its agencies, and United States personnel, by agents or employees of the Parent or persons claiming through them, or by third parties, and will hold the United States, its agencies, and United States personnel, harmless against every such claim or suit, including attorney fees, costs, and expenses, arising out of participating in this 18 WG/HC Field Trip.

Exceptions: Death, injury, damage to persons or property resulting solely from the willful misconduct of United States personnel shall not be affected by this Hold Harmless Agreement. Nothing in this agrees waives rights under Article XVIII of the U.S.-Japan Status of Forces Agreement (SOFA).

4. For the purpose of this Hold Harmless Agreement, the term “United States personnel” shall include:

a. Military personnel and civilian employees of the United States, including non-appropriated fund employees, acting within the scope of their employment,

b. Contractor personnel supporting activities of the Chapel acting within the scope of their contracts and the scope of their employment;

c. Volunteers acting in support of the activities of the Chapel; and

d. Heirs, successors, executors, administrators, and assigns of such employees.

___________________________ _________________________ __________

Printed Name of Parent/Guardian Signature of Parent/ Guardian Date

___________________________ _________________________ __________

Home Phone # of Parent/Guardian Cell Phone Work Phone

___________________________ _________________________ __________

Printed Name of Witness: Signature of Witness Date

In the event that emergency medical treatment is needed, the child must have his/her dependant Identification Card on their person in order to obtain treatment; children who have ID cards will not be allowed to participate in the Field Trip without their ID cards.

In the event the parent/guardian cannot be contacted, please list other

EMERGENCY CONTACTS:

Name: __________________________________ Phone/Cell: _________________________

Name: __________________________________ Phone/Cell: _________________________