Note: Please allow 20-30 minutes to read and complete this form in its entirety. Before filling out this form, you will need to have purchased your international flights and your international health and evacuation insurance.
I, the Participant, desire to participate in an HIH site visit and engage in the activities related to this program. I understand that the activities may include but are not limited to: traveling to/from other countries, traveling to/from other cities/towns, traveling to/from remote areas, consuming food and living in accommodations available in foreign countries, and being in health care settings.
I hereby freely and voluntarily, without duress, execute this Release under the following terms:
Waiver and Release. I, the Participant, release and forever discharge and hold harmless HIH and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my participant work with HIH.
I understand and acknowledge that this Release discharges HIH from any liability or claim that I, the Participant, may have against HIH with respect to any bodily injury, personal injury, illness, death, or property damage that may result from my participation with HIH, whether caused by the negligence of HIH or its directors, officers, employees, or agents or otherwise. I also understand that HIH does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance, in the event of injury, illness, death or property damage (see insurance requirements below).
Insurance. I, the Participant, understand that, except as otherwise agreed to by HIH in writing, HIH does not carry or maintain health, medical, or disability insurance coverage for any participant.
Medical Treatment. I hereby release and forever discharge HIH from any claim whatsoever which arises or may hereafter arise on account of any first-aid, medical treatment, or other services rendered on my behalf in connection with my work with HIH.
Assumption of the Risk. I recognize and understand that my time with HIH will include activities that are inherently hazardous. I understand that there is some inherent risk in consuming local foods and living in local accommodations available in the countries visited. I understand that all forms of travel to and in a foreign country pose inherent risks. And I understand that I may be traveling to and from locations where there is a risk of terrorism, war, insurrection, criminal activity, inclement weather, or other circumstance that could threaten my safety or health.
I also understand that, in order to protect its employees and participants in all countries around the world, HIH will not pay ransom or make any other payments in order to secure the release of hostages.
I hereby expressly and specifically assume the risk of injury or harm in these activities and release HIH from all liability for injury, illness, death, or property damage resulting from the activities of my time with HIH.
Choice of Law. I agree that Massachusetts law will apply, not withstanding any choice of law rules, to any litigation that might arise from my relationship with HIH.
Photographic Release. I grant and convey unto HIH all right, title, and interest in any and all photographic images and video or audio recordings made by HIH during my work for HIH, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
Other. I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Massachusetts in the United States of America, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Massachusetts. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.
I further understand that the statements contained in the guide are not intended to create any contractual or other legal obligations. I also recognize that Health In Harmony may modify or rescind any of its policies or practices described in this document at any time.
I will abide by the laws of the country I am visiting and will be respectful of the hosts and the partner organization.
I will participate or engage in the agreed-upon project or program schedule.
I will refrain from smoking and from using illegal drugs.
I will limit (or abstain from altogether) my alcohol intake so as not to impair my judgment and/or impact my ability to function as a responsible group member. I will never be visibly intoxicated.
I will adhere to the guidelines and cultural norms regarding dress, as outlined in the Visitor Guide.
I will treat program facilitators, ASRI staff, and community members with respect. I will not speak in a manner that is rude, offensive, or aggressive.
I will not be violent or participate in any violent act or activity.
I will not act in a way that will put myself or others in danger.
I will refrain from co-habitating with my partner if I am a member of an unmarried couple. I will also refrain from public displays of affection.
I will be flexible, as I understand that I am not in my home country/culture, and that not everything will go as I may want, or as according to plan.
I will be aware and respectful in the way I take photographs. I will seek permission, when possible, to take someone’s photo.
I have filled out the above Visitor Form to the best of my ability and knowledge, and I fully accept the above terms. *
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