How do I submit a release of liability form?

In preparation for the clinic, please submit a Release of Liability (ROL):

1. Print the ROL document.

2. Fill out page 1 completely.

3. Initial ALL pages.

4. Sign and date page 4 in front of a witness. Witness must be 18 years or older.

5. Have the witness sign and date the ROL.

 

There are two ways to get the ROL to us:

1. If you are able to scan ALL pages to a SINGLE PDF file, you can email the PDF to This email address is being protected from spambots. You need JavaScript enabled to view it..  In this case, you can discard the paper version.

2. If you prefer to send the ROL through the postal service or are unable to scan to a single PDF, mail the original ROL to:

               Flying Samaritans - Mother Lode Chapter

               PO Box 4312

               Stockton, CA 95204

Please make sure we have the ROL at least 15 days before the scheduled clinic departure.