Limited Power of Attorney/Parental Consent/Liability Release (Text)

LIMITED POWER OF ATTORNEY
CONSENT TO TRAVEL AND VISIT AND
RELEASE OF LIABILITY

I, the undersigned, am the natural father/natural mother/legal guardian/of _____ [name], a minor of the age of _____ [age] years. I hereby appoint [blanks for three names] as my attorneys-in-fact, jointly and severally, to take any and all action any of such deem fit with respect to the welfare and custody of said minor, including disciplining, supervising, and authorizing medical care and treatment. This limited power of attorney shall be effective commencing immediately and remaining in effect until written notice of written revocation is made to each said attorney-in-fact. This power of attorney shall be valid and effective at all times that said minor is not in my physical custody and is engaged in an activity sponsored directly or indirectly by Peoples Temple of the Disciples of Christ, also known as Peoples Temple Christian Church. In the event any of the aforesaid attorneys-in-fact are unable or unwilling to act as an attorney-in-fact, he or she may designate any other adult member of said church as attorney-in-fact in his or her stead.

I further give my consent to said minor traveling on the buses of said church and to participate in any and all transportation and visitation activities sponsored directly or indirectly by said church during the aforesaid period of time.

I further release Peoples Temple of the Disciples of Christ, its Pastor, its bus drivers, and all members of said church from any and all liability for any injuries resulting in any acts of commission or omission occurring while said minor is in any way engaged in an activity or on any trip sponsored directly or indirectly by Peoples Temple Christian Church.

(Note: use the same attorneys-in-fact as on Parental Consent form.)

[Page 2]

[Signature line]
Executed on this ____ day of _____,
197___, at _____ [Location], California.

ACKNOWLEDGMENT

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: _____

[Pages 3 and 4 are the duplicate of pages 1 and 2]

[Page 5]

PARENTAL CONSENT
AND POWER OF ATTORNEY

STATE OF CALIFORNIA
COUNTY OF SAN FRANCISCO
UNITED STATES OF AMERICA

I, [name], hereby declare:

  1. I am the natural _____ [mother or father]/legal guardian/of _____ [name of minor], a minor, born _____ [birthdate].
  2. I hereby consent to said minor going to Guyana, South America, to live and be cared for there under the Guardianship or custody of _____ [name] or whomever she appoints in her place.

I hereby appoint [spaces for three names and addresses] as my attorneys-in-fact, jointly and severally, to take any and all action any of them deem fit for the welfare of said minor. By this power of attorney, I give each of the aforesaid attorneys-in-fact the right to the care, custody, supervision, and control of said minor anywhere throughout the world, and to travel anywhere with said minor throughout the world.

Executed on this [date],
197___, at ____ [location], California
SIGNED ____

[Page 6]

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: _____

[Pages 7 and 8 are the duplicate of pages 5 and 6]

[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]

Originally posted on January 29th, 2020.

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