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ASSUMPTION OF RISK, RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION - {{gravity-field-id-1}}

This form is to be completed by adults (age 18 or older on the trip departure date) and is not required for minors (under the age of 18). Minors must submit the completed Parental Consent, Certification, and Medical Authorization form, which must be completed by their authorized parent or legal guardian and notarized.

PART 1—Assumption of Risk

I, (name of TEAM MEMBER/VOLUNTEER: first, middle initial and last name) of Church: , attending a trip to , in consideration of my acceptance as a short-term volunteer with OneHope, Inc. (“OneHope”) that:

I am a volunteer worker and acknowledge that I am not an employee of ONEHOPE:
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, terrorist 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 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 (Corinthians 11:23-28).
I attest and certify that I have no medical conditions that would prevent me from performing my duties.
Subject to insurance coverage described below, I waive and release any and all claims for damages which I, or my heirs or successors, may have against ONEHOPE, the local church sponsoring the OneHope trip, or any agent or employee of any such organization, 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.
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 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.
I understand and accept the following policy of ONEHOPE regarding ransom payments and understand that this is the policy of ONEHOPE, and all affiliated agencies:
OneHope Teams has determined that it will not pay ransom nor yield to the demands of anyone who takes one of our missionary family or staff hostage. OneHope Teams 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.
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.
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.
“RELEASE FROM LIABILITY. I on behalf of myself and/or my child fully and forever release and discharge OneHope, Inc. and its respective affiliates, directors, officers, shareholders, employees, agents, and insurers, and all others involved in the Mission Trip from any and all injuries (including death), losses, damages, claims (including negligence claims), demands, lawsuits, expenses, and any other liability of any kind, of or to me or my child, our property, or any other person, directly or indirectly arising out of or in connection with my participation in the Mission Trip.”

PART 2—Insurance

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 ONEHOPE currently requires the insurance coverage summarized below and is providing such coverage on my behalf for the duration of my ministry through IM Global to International Medical Group (IMG) policy. I accept this coverage provided on my behalf by ONEHOPE. I understand that I am not covered during any divergences in itinerary that I willingly make, to include, but not limited to, unnecessary stopovers made in transit.

I also understand that the coverage (as detailed below) is supplemental to insurance coverage I already have, and that I am responsible for obtaining any additional insurance coverage that I consider necessary. I understand that additional insurance details will be forthcoming prior to my trip.

Outreach Group Travel Medical Insurance Insurance Coverage:

PLAN INFORMATION
Maximum Limits Individual Deductible	$250,000 $0
MEDICAL BENEFITS	USUAL, REASONABLE AND CUSTOMARY CHARGES, SUBJECT TO DEDUCTIBLE AND COINSURANCE WHEN APPLICABLE.
Hospital Room and Board Intensive Care Medical Expenses Out-patient Medical Local Ambulance Prescription Drugs Emergency Room Accident Emergency Illness - with In-patient Admission Emergency Illness - without In-patient Admission	Up to the Maximum Limit for average semi-private room rate Up to the Maximum Limit Up to the Maximum Limit Up to the Maximum Limit Up to the Maximum Limit Up to the Maximum Limit Up to the Maximum Limit Up to the Maximum Limit Up to the Maximum Limit
INTERNATIONAL EMERGENCY CARE	(WHEN COORDINATED THROUGH THE PLAN ADMINISTRATOR)
Emergency Evacuation Emergency Reunion Return of Mortal Remains Return of Minor Children Political Evacuation Natural Disaster Identity Theft Assistance	Up to $500,000 lifetime maximum (independent of the Maximum Limit) Up to $50,000 Up to $50,000 Up to $50,000 Up to $10,000 $100 per day for five days Up to $500 per Period of Coverage
ADDITIONAL BENEFITS
Terrorism Coverage Sports & Activities Coverage Incidental Home Country Coverage Trip Interruption Common Carrier Accidental Death Accidental Death & Dismemberment Lost Luggage	Up to $50,000 lifetime maximum Up to the Maximum Limit for basic sports Coverage as described below Up to a cumulative two weeks Up to $5,000 $50,000 to Beneficiary; maximum of $250,000 per family $25,000 principal sum Up to $50 per item of personal property; maximum of $250 per Period of Coverage

PART 3—Photography and Background Checks

Photography Release

I, , give ONEHOPE the irrevocable and unrestricted right and permission to use my photograph in its publications, electronic reproductions (web sites) and/or promotional materials or any other purpose and in any manner or medium. I release ONEHOPE, the photographer, their offices, employees, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. I am 18 years of age or older.

Initials: April 19, 2024

Background Check Release:
Please note: Background checks are required to be performed on all team members in compliance with ONEHOPE policy, using a verified and professional company, Accurate Background, Inc. (www.accuratebackground.com). Social Security Numbers will not be used for anything other than a background check, and all numbers will be stricken from any printed record.

I authorize ONEHOPE to perform a background check for any criminal records.

Social Security Number: Date of Birth

Initials: April 19, 2024

Part 4 - DISCLOSURE AND CONSENT TO USE OF ELECTRONIC SIGNATURE

OneHope, Inc. (the “OneHope”) has implemented an Electronic Signature Program, whereby you will have the option to sign certain documents electronically, which will be treated like a physical handwritten signature. In order to use this new system, you need to read and consent to the information provided below.

You may choose not to consent to use an electronic signature. However, OneHope encourages you to consider the benefits of using an electronic signature—better data accuracy, a greener approach to paper management, and less of a burden for OneHope staff.
You have the right at any time to withdraw your consent of having records provided to you electronically. To withdraw your consent, please contact OneHope by calling 1-800-448-2425 or sending an e-mail to teams@onehope.net. If you withdraw your consent, OneHope will mail you paper copies of the records OneHope is required to make after the withdrawal of your consent; however, the withdrawal of your consent will not affect the legal validity or enforceability of any documents you have previously signed electronically.
You have the right to obtain a paper copy of an electronic record. If you wish to request a paper copy, please contact OneHope by calling 1-800-448-2425 or sending an e-mail to teams@onehope.net. OneHope’s fees for paper copies may change from time to time, and you may obtain information about such fees by contacting OneHope.
By signing below, you agree to receive disclosures, terms and conditions, forms, documents, or contracts electronically (including, Mission Trip Assumption of Risk, Release of Liability and Medical Information Form, FCRA Disclosure of Intent to Obtain Consumer Reports and Investigative Consumer Reports, Background Screening Consent and Authorization, activity releases, authorizations to release records, and other ministry related consents, waivers and forms) as well as conduct all transactions with OneHope electronically in lieu of a paper copy. Specifically, you are consenting to use electronic documents, e-mail delivery of documents, and electronic signatures in any communication or agreement involving you and OneHope.
To help ensure the authenticity and security of each document you sign with an electronic signature, only you will be able to access your documents through a unique URL that will be e-mailed to you at the address you provide to OneHope. You will also receive e-mail confirmation when you sign a document electronically. To effectively participate in the Electronic Signature Program, if your e-mail address changes, you must inform OneHope immediately.

In order to access and retain your electronic records, you must have a computer or other device capable of accessing the Internet, an Internet Web Browser, an active e-mail account, and a PDF reader for viewing and printing documents, such as Adobe Reader. By providing your consent, you are confirming you have the hardware and software described above and that you are able to receive and view electronic records.
You agree and consent that your use of a keypad, mouse, or other device to select an item, button, icon, checkbox, or to enter text or perform a similar action (e.g., by typing in your name and clicking on “Submit My Electronic Signature”), constitutes your electronic signature and signifies your intent to be bound. You understand that your electronic signature is legally binding, just as if you manually signed a paper document in ink.

ELECTRONIC SIGNATURE

I have read, understand, and agree to the terms and conditions of this Disclosure and Consent to Use of Electronic Signature. I hereby consent to conduct all transactions with OneHope by electronic means. I specifically agree to the use of electronic documents, e-mail delivery of documents, and electronic signatures in any communication or agreement involving me and OneHope. I understand that my electronic signature is legally binding and that my electronic signature may not be invalidated solely on the basis that the signature was electronically obtained. I understand that I may decline to complete documents electronically by clicking “Cancel” below. However, if I decline, I understand that I will be required to contact OneHope via telephone at 1-800-448-2425 or via e-mail at teams@onehope.net to obtain any paper copy documents I may need to sign in order to participate in OneHope sponsored Mission Trips.

Print Full Name

Date

PART 4—Health Information:

Last Name First Name

Age D.O.B

Address

City State Zip

Sex

Male

Female

Height Weight

Blood Type (if known)

In case of an emergency, notify , Relationship Phone Number

Have you ever suffered a serious illness, had surgery performed or been hospitalized?

Yes

If yes, please explain, if not please leave blank

Do you have any known allergies?

Yes

If yes, please list:

Do you have any dietary restrictions or food allergies?

Yes

If yes, please list:

Have you ever been treated for (or are now suffering from) emotional difficulties?

Yes

If yes, please explain:

Do you have a communicable disease?

Yes

If yes, please list:

Do you have any physical limitations?

Yes

If yes, Please explain:

IMMUNIZATIONS:

For our information please indicate date of most recent immunization, if known.

Poliomyelitis
Diphtheria
Hepatitis A
Hepatitis B
Measles/Mumps/Rubella
Tetanus
Malaria
Other

Physician’s Name:
Office Phone:

Initials: April 19, 2024

FCRA DISCLOSURE AND AUTHORIZATION TO OBTAIN CONSUMER AND/OR INVESTIGATIVE REPORT

The Organization, OneHope, Inc.(“Company”) may obtain information about you for mission trip purposes from a third party consumer reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, supervisors, or associates. These reports may contain information regarding your criminal history, social security verification or other background checks. Further, you understand that information may be requested from various Federal, State, County and other agencies that maintain records concerning your past activities relating to your criminal, civil, and other experiences.

You have the right, upon written request made within a reasonable period of time after receipt of this notice, to request whether a consumer report has been conducted about you, disclosure of the nature and scope of any investigative consumer report, and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for mission trips is an investigation into your Criminal history. The scope of this notice and authorization is all-encompassing, however, allowing the Company to obtain consumer reports and investigative consumer reports now and throughout the course of your trip to the extent permitted by law, unless you otherwise revoke your consent by providing written notification to Company. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

The consumer and/or investigative consumer report(s) will be obtained from:
Accurate Background, Inc., 7515 Irvine Center Drive, Irvine, CA 92618, (800) 216-8024.
Accurate Background’s information and privacy policy can be found at www.accuratebackground.com

California applicants or employees only: By signing below, you also acknowledge receipt of A SUMMARY OF YOUR RIGHTS UNDER THE PROVISIONS OF CALIFORNIA CIVIL CODE §1786.22.

Minnesota and Oklahoma applicants or employees only: Please check the appropriate box below if you would like to receive a copy of your consumer report free of charge.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Company by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.

New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing the authorization, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer identity theft protection, the storage and disposal of your credit information, and remedies available should you suspect or find that the Company has not maintained secured records is available to you upon request.

Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the DISCLOSURE REGARDING CONSUMER AND/OR INVESTIGATIVE REPORT and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, local, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Accurate Background, Inc., 7515 Irvine Center Drive, Irvine, CA 92618 (800) 216-8024, www.accuratebackground.com, another outside organization acting on behalf of the Company, and/or the Company itself.

I understand that by signing my name below, that I am signing the Authorization form directing the background check as described above,
and I certify that:

I have received the Disclosure Regarding Consumer and/or Investigative Report, have read and received the Summary of Your Rights, and if a California resident/applicant, the A Summary of Your Rights Under the Provisions of California Civil Code §1786.22.
I understand that my signature now and throughout this process will be binding. Additionally, notices, documents, and communications may be provided electronically and will meet the requirements set forth under Federal and/or State law, as permitted by law. I agree that a facsimile (“fax”), electronic or printout of this authorization may be accepted with the same authority as the original.

For California, Oklahoma, or Minnesota employees and applicants: Please check the appropriate box to indicate if you would like to receive a copy of your consumer report free of charge. Copy of background

Yes

Full Name :

Other Names Known By:

Social Security Number:

D.O.B

Current Address:

City State Zip

Phone Number:

Candidate Entry Criminal History Question

Have you ever been convicted of, plead guilty, no contest or nolo contendere, to a misdemeanor or felony?*

*Do not report any conviction that has been sealed, expunged, statutorily eradicated, annulled, impounded, erased, dismissed, dismissed under a first offender’s law, pardoned by the Governor or which state law allows you to lawfully deny as set forth below. You must review the state law information below before answering. You are also not required to disclose violations, infractions, petty misdemeanors or summary offenses.

A conviction will not necessarily be a bar to employment. This information will only be used for job-related purposes consistent with applicable law and is only relevant in determining whether the conviction is related to the job for which you are applying. Factors such as age at the time of the offense(s), recentness of the offense(s), seriousness of the offense(s), nature of the violation(s), its relation, if any, to the job you are seeking, and rehabilitation will be taken into account. Failure to honestly answer this question may result in discontinued consideration of your application or termination of employment.

* California employees/residents: You need not disclose any referral to, and participation in, any pre-trial or post-trial diversion program, or any misdemeanor convictions for which probation has been successfully completed and discharged. Do not list any marijuana-related misdemeanor convictions over two years old, or felony marijuana convictions under California Health and Safety Code Section 11360 (c) which occurred prior to 1976.
* Connecticut employees/residents: You need not disclose any conviction record that has been erased pursuant to sections 46b-146, 54-76o or 54-142a of the Connecticut General Statutes. Records subject to erasure under these sections are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that was dismissed or nolled, or a criminal charge for which the person was found not guilty or received an absolute pardoned conviction. Any person whose records were erased within the meaning of these three sections may consider such events to have never occurred and may so swear under oath.
* Massachusetts employees/residents: An applicant for employment with a sealed record on file with the commissioner of probation may answer “no” to the above with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for employment may answer “no” to the above with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution.
You may exclude information regarding first convictions for the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace, or a conviction for any misdemeanor where the conviction occurred or any prison sentence ended five or more years ago whichever date is later, unless you have been convicted of another offense within the last 5 years.
* Philadelphia, PA employees/residents: You may exclude convictions occurring more than seven years from the date of the inquiry. Any period of incarceration should not be included in the calculation of the seven year period.
* San Francisco, CA employees/residents: You may exclude convictions that occurred over seven years ago and a conviction or any other determination or adjudication in the juvenile justice system, or information regarding a matter considered in or processed through the juvenile justice system.
* Seattle, WA employees/residents: In addition to the below, you may exclude a criminal conviction that has been the subject of a certificate of rehabilitation or other equivalent procedure based on a finding of the rehabilitation.
* Washington State employees/residents: You may exclude convictions that occurred over ten years ago

Yes

If you answered Yes to the question above, provide city, county, and state of conviction and date and nature of the offense, along with sentencing information. Please also provide any other information you would like the Company to consider including but not limited to: the time that has elapsed since the offense(s), your age at the time of the offense(s), facts or circumstances surrounding the offense(s), the number of offenses for which you have been convicted, your employment history before and after each conviction, evidence of rehabilitation, and/or other mitigating factors.

ELECTRONIC SIGNATURE

By typing my name below and clicking “Agree & Sign,” I hereby attach my electronic signature. I understand that my electronic signature is legally binding and may not be invalidated solely on the basis that my signature was electronically obtained. I understand that I may decline to complete these forms electronically by not submitting this form. However, if I decline, I understand that I will not be allowed to participate in OneHope sponsored mission trips until such time as I contact OneHope via telephone at 1-800-448-2425 or via e-mail at teams@onehope.net and manually execute the Mission Trip Assumption of Risk, Release of Liability and Medical Information Form.

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January 2, 2019 5:17 pm EDT

ASSUMPTION OF RISK, RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION - {{gravity-field-id-1}} Uploaded by OneHope Teams - samdavis@onehope.net IP 45.42.62.131

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