I hereby declare I am the ____ of _____, a minor, and have full legal custody thereof, and enter into this release of liability with respect to myself and said minor.
I hereby release Peoples Temple of the Disciples of Christ, a California corporation, and any and all of its members, and Pastor Jim Jones, of any and all liability, claims, causes, and causes of action arising out of or relating to said minor’s travels to and from and visits in any and all foreign countries including Guyana, South America, including but not limited to the airplane flights to and from said destination and accompanying means of transportation while there.
In the event that I should elect that said minor remained for a period of time that such destination, including Guyana, South America, I hereby release Peoples Temple of the Disciples of Christ, a California corporation, and any and all of its members, and Pastor Jim Jones, of any and all liability arising out of or related to said minor’s activities, travel, and any illnesses that might arise by natural or other causes while there.
I hereby acknowledge that I have requested said corporation and said members and said Pastor that said minor may go on said trip and remained in said places. If said minor is permitted to remain at any such place, I hereby promise along his/her behalf that he/she will work diligently and in full cooperation with all leadership appointed by said Pastor, directly or indirectly, and will keep a cheerful and constructive attitude at all times. If said minor fails to keep this promise, it is understood that I will be solely responsible for any and all costs and other obligations incurred and said minor’s returning from as well is going to and living in said place.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this _____ day of _____, 197__, at _____, California.
SIGNED
State of California
County of
United States of America
On _____, before me, the Undersigned, a notary public in and for said county and state, personally appeared _____, known to me to be the person whose name __ subscribed to the within instruments and acknowledged to me that __ executed the same.
Witness my hand and official seal _____
Wkr___