ASSUMPTION OF RISK, RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION
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.
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 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:
Maximum Limits Individual Deductible
USUAL, REASONABLE AND CUSTOMARY CHARGES, SUBJECT TO DEDUCTIBLE AND COINSURANCE WHEN APPLICABLE.
Hospital Room and BoardIntensive CareMedical Expenses Out-patient MedicalLocal Ambulance Prescription DrugsEmergency Room AccidentEmergency Illness - with In-patient AdmissionEmergency Illness - without In-patient Admission
Up to the Maximum Limit for average semi-private room rateUp to the Maximum LimitUp to the Maximum LimitUp to the Maximum LimitUp to the Maximum LimitUp to the Maximum LimitUp to the Maximum LimitUp to the Maximum LimitUp to the Maximum Limit
INTERNATIONAL EMERGENCY CARE
(WHEN COORDINATED THROUGH THE PLAN ADMINISTRATOR)
Emergency Evacuation Emergency Reunion Return of Mortal RemainsReturn of Minor ChildrenPolitical EvacuationNatural DisasterIdentity Theft Assistance
Up to $500,000 lifetime maximum (independent of the Maximum Limit)Up to $50,000Up to $50,000Up to $50,000Up to $10,000$100 per day for five daysUp to $500 per Period of Coverage
Terrorism Coverage Sports & Activities Coverage
Incidental Home Country CoverageTrip Interruption Common Carrier Accidental Death
Accidental Death & Dismemberment Lost Luggage
Up to $50,000 lifetime maximumUp to the Maximum Limit for basic sports Coverage as described belowUp to a cumulative two weeksUp to $5,000$50,000 to Beneficiary; maximum of $250,000 per family$25,000 principal sumUp to $50 per item of personal property; maximum of $250 per Period of Coverage
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: December 8, 2022
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: December 8, 2022
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.
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 email@example.com to obtain any paper copy documents I may need to sign in order to participate in OneHope sponsored Mission Trips.
Print Full Name
Last Name First Name
City State Zip
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?
If yes, please explain, if not please leave blank
Do you have any known allergies?
If yes, please list:
Do you have any dietary restrictions or food allergies?
Have you ever been treated for (or are now suffering from) emotional difficulties?
If yes, please explain:
Do you have a communicable disease?
If yes, please list:
Do you have any physical limitations?
If yes, Please explain:
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: December 8, 2022
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.
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:
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
Full Name :
Other Names Known By:
Social Security Number:
City State Zip
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
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.
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 firstname.lastname@example.org and manually execute the Mission Trip Assumption of Risk, Release of Liability and Medical Information Form.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: ASSUMPTION OF RISK, RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION
Agree & Sign