The Iraq Sanctions Challenge
39 West 14 Street, #206, New York, NY 10011
RELEASE

Concerning the program of the Iraq Sanctions Challenge, in which I intend to participate, I understand the following:

1. There are differences in climate, living conditions, diet, and water quality between Iraq and my country of residence;
2. I may be provided with housing that is very simple and that involves sharing a room with other delegates;
3. Access to medical care (including emergency care) may be different than in the U.S.;
4. While every effort will be made to respond to my health care needs, if care is necessary, it may be different than the care I would receive in my country of residence;
5. I have fully informed the Iraq Sanctions Challenge of any condition(s) of my mental, emotional, or physical health that may affect my participation in the program;
6. I authorize the designated health care providers of the Iraq Sanctions Challenge and/or United States, Jordanian or Iraqi medical personnel, as may be required, to provide emergency medical treatment for me in the event that I am unable to give consent;
7. The Iraq Sanctions Challenge will not be responsible for any injury or accident which befalls any person via incidents connected with the operation or maintenance of any vehicles, or the handling of the goods to be transported in these vehicles, in any way whatsoever;
8. It is my responsibility to arrange for my own transportation and housing to any point or destination to which I may wish to travel after leaving the Iraq Sanctions Challenge;
9. It is my responsibility to cooperate fully with the staff and decision-making structure of the Iraq Sanctions Challenge;
10. I understand that many of the decisions during the trip will be made by a steering committee composed of representatives elected and/or appointed by the Iraq Sanctions Challenge, including myself, or by staff members. I understand that, due to time constraints and the difficulties of the trip, I will not be consulted on many of the decisions made during the trip. I agree to abide by the decisions of the steering committee and the staff.

With the above understanding, and in consideration of my voluntary participation in the Iraq Sanctions Challenge, I completely accept and assume all responsibility for any and all risks of damage or personal injury which occur during or result from my participation in the Iraq Sanctions Challenge including, but not limited to, those risks described above;

FURTHER, I also hereby release, discharge, and agree to hold harmless the Iraq Sanctions Challenge project, members, staff, directors, officers, and its advisory committee organizations, their members, staff, directors, or officers, from liability, claims, demands, rights or causes of action, present or future, whether known or unknown, anticipated or unanticipated, whether brought on by my own behalf or by or for any other person, or my heirs, executors, or assigns for personal illness, injuries or death, or any damage to or loss of personal property which may occur during or result from my participation in the program;

FURTHER, my intention in signing this document is to expressly release, discharge and hold harmless the Iraq Sanctions Challenge and the persons described above to the maximum extent permitted by law in any state, territory, district, or country. I expressly waive any statute which would otherwise prohibit or limit the release or discharge of future unknown or unanticipated claims, demands, injuries, or damages;

FURTHER, I declare and represent that no promise, inducement, or agreement not expressed above has been made to me.

I am at least eighteen years of age. I have carefully read the foregoing release and fully understand its contents.

____________________________________ Subscribed and sworn to before me

Signature
the day of _______
___________________________________
Name printed or typed

(Notary public) My commission expires ____________________

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