LIABILITY RELEASE FORM

SUMMER MEDICAL INSTITUTE 2004

SOUTH AFRICA

I, _____________________________, release Medical Campus Outreach and its staff, East Cooper Baptist Church, and First Presbyterian Church of Augusta from all liability concerning and surrounding my participation and actions in the Summer Medical Institute 2004 and/or College of Health Professions and Dental Project. I will hold the above parties harmless for actions which are a result of my involvement and participation including but not limited to transportation to and from activities, the health care activities themselves, any course of medical treatment and any activities taking place on the property of the parties.

Furthermore, I promise not to initiate any action, whether in law, equity, or administratively, through any agency, to recover any remedy against Medical Campus Outreach and its staff, East Cooper Baptist Church, and First Presbyterian Church of Augusta for or deriving from the activities listed above, nor will I appoint any attorney at law or in fact, to initiate any such action on my behalf.

This agreement is binding on all heirs, guardians, assignees, or anyone else who may be legally enabled to bring actions on my behalf.

Intending to be legally bound, I have signed below.

____________________________ ___________

SIGNATURE DATE