Liability Release (Text)

[Page 9]

RELEASE
AS TO SELF AND MINOR

I hereby declare that I am the [relationship] of [name], 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 and relating to said minor’s travels to and from and visit 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 remain for a period of time in 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 said minor may go on said trip and remain in said places. If said minor is permitted to remain in any such place, I hereby promise on his/her behalf that he/she will 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 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 in said minor’s returning from as well as 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 ___,
19__, at _______, California.
SIGNED:_________

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: _____

[Page 10 is the duplicate of page 9]

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The forms all appear in RYMUR 89-4286-B-1-a-, with the page number(s) indicated below. The names of the minors are in alphabetical order. The date of signature also appears next to the name.

RELEASE AS TO SELF AND MINOR