PART 1--Assumption of Risk

      I, ____________________________________ (name of volunteer), in consideration of my acceptance as a short-term volunteer with the Missions Abroad Placement Service (MAPS) of the Division of Foreign Missions of the General Council of Assemblies of God; USA, represent and agree that:

      1. I am a volunteer worker going to ________________________(country), and acknowledge that I am not an employee of MAPS, the Division of Foreign Missions of the Assemblies of God, or the General Council of Assemblies of God, USA.

       2. I am aware of the hazards and risks to my person and property associated with serving in a missions capacity, such hazards and risks including, but not being limited to, death or injury by accident, disease, war, terrorists acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence. I accept my assignment with full awareness of these risks, and, subject to the insurance coverage's described below, I voluntarily assume all risks of death, injury, illness, and damage to myself or any member of my family associated with such risks, and any damage to my personal property. I further recognize that such risks have always been associated with missionary service (2 Corinthians 11:23-28).

       3. I attest and certify that I have no medical conditions that would prevent me from performing my duties.

       4. Subject to insurance coverage's described below, I waive and release any and all claims for damages which I, or my heirs or successors, may have against MAPS, the Division of Foreign Missions of the Assemblies of God, the General Council of Assemblies of God, any District Council of the Assemblies of God, the local church sponsoring the MAPS trip, or any agent or employee of any of such organizations, arising from my death, injury, or illness, or any property damage or loss occurring during the term of my assignment or as a result of my assignment.

       5. In the event that I have minor children who will accompany me on my assignment, I, acting both on my own behalf and in their behalf as their parent and legal guardian, and subject to the insurance coverage's described below, do hereby assume all risks of death, illness, or injury that they may suffer as a result of said assignment, from those causes described above.

       6. I understand and accept the following policy of the Division of Foreign Missions regarding ransom payments;

The Foreign Missions Board has determined that it will not pay ransom nor yield to the demands of anyone who takes hostage one of our missionary family or staff hostage. The Division of Foreign Missions pledges itself to every effort in prayer and all other appropriate means to obtain the release of one taken hostage should it ever occur. This policy was made after sufficient study of the policies of other evangelical missionary societies and after considering the advice of the United States State Department.

       7. I expressly waive any defense to the enforcement of any provisions of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me enforceable against me in accordance with its terms.

       8. I expressly agree that this assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by law. I further state that I HAVE CAREFULLY READ THE FOREGOING ASSUMPTION OF RISK AND UNDERSTAND ITS CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT.
 

PART 2--INSURANCE ELECTION

       I am aware of the hazards and risks to my person associated with serving in a missions capacity, as described above. I further understand that MAPS currently requires insurance coverage (summarized below), that l am responsible for the cost of such insurance, that these coverage's are subject to change, and that I am responsible for obtaining any additional insurance coverage's that I consider necessary:

• $100,000 24-hour accidental death and dismemberment
• $1,000 monthly limit for permanent total disability based on an accident (100-month maximum, with a 12-month waiting period)
• $1,000 monthly limit for permanent total disability based on illness (50-month maximum, with a 12-month waiting period)
• $50,000 accident medical limit
• $10,000 sickness medical limit
• $50 deductible per occurrence
• $75,000 medical evacuation limit
• $10,000 repatriation limit

_____ I have adequate insurance coverage and do not desire the insurance coverage described above.
                (Proof of insurance must accompany this form)

_____ I desire the above-described insurance coverage with American International Group (AIG)

SIGNATURES
Date: __________

__________________________________                                 _________________________
Legible signature                                                                     Address

__________________________________                                 _________________________
Legible signature of spouse (if he or she will                            Address
accompany you on your assignment)

IMPORTANT: Please have two (2) witnesses observe your signing of this form, and have the witnesses sign below. They must be at least 18 years old, and they cannot be your relatives.

__________________________________                                 _________________________
Witness' legible signature                                                        Address

__________________________________                                 _________________________
Witness' legible signature                                                        Address