Mercy Mission Malaysia,
No.20, Jalan Teknologi 3/3A, Surian Industrial Park,
Kota Damansara PJU 5, 47810 Petaling Jaya,
Selangor, Malaysia.

Participant Information

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Household / Adult Primary Contact

Relationship to Participants: *

Waiver and Release of Liability

Please read this form carefully and be aware in registering your child for participation in the program or programs listed you will be waiving and releasing all claims for injuries you or your child might sustain arising from that program.

Important Information

Mercy Mission Malaysia is committed to conducting its programs and activities in the safest manner possible and holds the safety of participants in the highest possible regard. Participants and parents registering their children in programs and activities must recognize, however, that there is an inherent risk of injury when choosing to participate. Mercy Mission Malaysia strives to reduce such risks and insists that all participants follow safety rules and instructions which have been designed to protect the participant's safety.

Please recognize that Mercy Mission Malaysia does not carry medical accident insurance for injuries sustained in its programs and activities. The cost of such medical expense would make program fees prohibitive. Therefore, each person registering themselves or a family member for a program or activity should review their own medical insurance policy for coverage. It must be noted that the absence of medical insurance coverage does not make Mercy Mission Malaysia automatically responsible for the payment of medical expenses. Your cooperation is greatly appreciated.

Waiver and Hold Harmless Agreement

As the parent/guardian of a participant in this program, you recognize and acknowledge that there are certain risks of physical injury arising out of this program and agree to assume full risk of any injury, damage or loss which your child may sustain as a result of participating in any and all activities associated with this program. You agree to waive, release, discharge and/or relinquish all claims or accrued costs you may have as a result of your child participating in this program against Mercy Mission Malaysia, its Board of Directors, officers, representatives, agents, employees and volunteers.

You further agree to indemnify, hold harmless, and defend Mercy Mission Malaysia, its Board of Directors, officers, representatives, agents, employees and volunteers from any and all claims resulting from injuries, damages and losses sustained by your child and arising out of, connected with or in any way associated with the activities of the program.

In addition, Mercy Mission Malaysia, its Board of Directors, officers, representatives, agents, employees and volunteers are not liable for any loss or damage of personal property during the program.

Media Release

The undersigned authorizes Mercy Mission Malaysia to use and display any videos, photographs or still images of me or my child taken while engaged in activities in any publication, multimedia production, display, advertisement or other publication, electronic and/or print. The undersigned releases and forever discharges Mercy Mission Malaysia, as well, as their agents, officers, volunteers and employees from any and all claims and demands, monetary or otherwise, arising out of or in connection with the use of said photographs/images.

Medical Treatment Authorization

I, the undersigned further understands that, in the event my child requires medical or dental treatment while engaged in activities with Mercy Mission Malaysia, reasonable efforts will be made to contact me or the emergency contact provided; however, if I or the emergency contact cannot be reached, I hereby consent and give permission to the any director, trustee, officer, employee, agent or volunteer acting on behalf of Mercy Mission Malaysia as agent for me, to consent to any X-ray examination; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician; surgeon, or dentist (as appropriate) licensed to practice under the law of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child’s medical allergies, medications being taken, medical problems, and other pertinent information. My child has my permission to participate in all prescribed activities except as noted by me.

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