Acknowledgement of Risks and Release from Liability
In consideration for being allowed to participate as a volunteer in the Penn Medicine in
Botswana project, organized and coordinated by the Department of Medicine of the
Clinical Practices of the University of Pennsylvania, I acknowledge and agree as follows:
Although the Department of Medicine has taken reasonable steps to provide appropriate
resources and guidance so that Penn Medicine in Botswana team members may
participate in activities for which they may be skilled, I acknowledge and appreciate that
such foreign volunteer service projects are not without risk. I understand that the
Department of Medicine is not in a position to guarantee my personal health or safety
during my participation in this project. Notwithstanding, the Department of Medicine
thinks it is important for each member of the Penn Medicine in Botswana team to be
informed of the inherent risks.
Penn Medicine in Botswana team members will travel to and from, work and live in
Gabarone, Botswana where they may be subject to numerous risks, environmental and
otherwise. Specific hazards include the risk of crime, exposure to communicable
diseases including, but not limited to, Tuberculosis, Hepatitis, Tetanus and HIV, as well
as the hazards of travel to, from and around Botswana, inadequate medical care and
remote access to medical treatment.
I am aware that the participation in foreign volunteer service project activities entails
risks. I understand that the description of these risks is not complete and that other
unknown or unanticipated risks may result in injury, illness or economic loss. I am
participating in these activities on a purely voluntary basis.
I assume full responsibility for all risks associated with my participation in this project
and I agree to hold harmless, release and forever discharge the Trustees of the University
of Pennsylvania, the School of Medicine of the University of Pennsylvania, the
Department of Medicine of the Clinical Practices of the University of Pennsylvania, the
University of Pennsylvania Health System, and their respective trustees, officers,
directors, employees, agents, faculty and students from and against any and all claims,
demands and causes of action of whatever kind that I may have including but, not limited
to, illness, bodily injury, imprisonment, death, and loss of personal property, or the
consequences thereof, resulting from or in any way connected with my participation in
the Penn Medicine in Botswana project.
By signing below, I certify that I am at least 18 years of age, that I have carefully read
this “Acknowledgement of Risks and Release from Liability” and understand it.
Signature: __________________________________________
Date: ____________
Print name: _____________________________________________________________
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Emergency Contact Information
Print Volunteer’s Name: ___________________________________________________
(First, Middle, Last/Surname)
Print Emergency contact and phone numbers:
1. Name: ____________________________________________________________
Phone # 1: Area Code (
) ___________________ Home/work/cell? _________
Phone # 2: Area Code (
) ___________________ Home/work/cell? _________
Email address: ________________________________________________________
2. Name: ____________________________________________________________
Phone # 1: Area Code (
) ___________________ Home/work/cell? _________
Phone # 2: Area Code (
) ___________________ Home/work/cell? _________
Email address: ________________________________________________________
**** **** **** **** **** **** **** **** **** **** **** ****
Permission for Medical Treatment
I hereby give permission to the medical personnel selected by the a member of the Penn
Medicine in Botswana team and/or the Botswana local officials to secure medical
evaluation and any treatment necessary to preserve life and bodily function unless
exceptions are noted below.
Exceptions: (if none, write “none”)
I am allergic to the following medications: _____________________________________
Other medical conditions that you wish for those providing treatment to be aware of:
Signature: ______________________________________ Date: ___________________
Print Name: _____________________________________
Please fax the Acknowledgement of Risks/Release and this Emergency Contact form to
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