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 and relating to, my travels to and from, and my visit in the United States 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 to remain for a period of time in any 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, claims, causes, and causes of action arising out of and related to my 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 I may go on said trip and remain in said places. If I am permitted to remain in any such place, I hereby promise to work diligently and in full co-operation with all leadership appointed by said Pastor, directly or indirectly, and to keep a cheerful and constructive attitude at all times. If I fail to keep this promise, it is understood that I will be solely responsible for any and all costs and other obligations incurred in my returning from as well as going to and living in said place.
This release shall apply in all of its terms to each of my minor children, dependents, and other persons as to whom I have legal custody or am otherwise responsible.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this ___ day of ___,
19__, at _______, California.
STATE OF CALIFORNIA
COUNTY OF SAN FRANCISCO
UNITED STATES OF AMERICA
On _____ [date], before me, the Undersigned, a Notary Public in and for said County and State, personally appeared _______[name], known to me to be the person whose name is subscribed to the within instruments and acknowledged to me that ___ executed the same.
WITNESS MY HAND AND OFFICIAL SEAL: _____
STATEMENT OF CUSTODY
As an inducement to Peoples Temple, its officers and staff, to permit _______[name], minor(s) under my custody and control, to travel with me overseas and reside in church facilities should I so desire, I hereby represent that I have lawful custody of said minor(s), and have legal authorization for them to travel and stay with me.
As a further inducement, I acknowledge that I have, and will have, complete and exclusive obligation for the care and control of said minor(s) during their travel and stay.
I declare under penalty of perjury that the foregoing is true and correct. Executed on _____ [date] at _____ [location].