Day of Mission

  • I, the undersigned Passenger, understand that LifeLine Inc. (dba LifeLine Pilots (“LLP”)) has arranged one or more flights or other transportation, free of charge, for my convenience in obtaining, assisting with, or returning from medical treatment or diagnosis, or for other humanitarian needs or flights of compassion. I understand that the pilots, operators, owners, and lessors of the aircraft and other vehicles (“Owners and Operators”) are volunteering their services, time, skills, flight, aircraft, vehicles, and/or other related costs and expenses for the proposed transportation. As such, I understand that LLP, those organizations providing connecting flights (“Partner Organizations”), Owners and Operators, and the other persons and entities released by me are relying on my release for their agreement to arrange and/or provide the transportation services. I also acknowledge that I and any Minors listed below are flying on the aircraft or riding in the vehicles voluntarily and with our full consent.

    I, on my own behalf and also on behalf of the Minor, and our personal representatives, heirs, next of kin, and assignees hereby forever RELEASE, DISCHARGE, WAIVE, HOLD HARMLESS, COVENANT NOT SUE, AND AGREE TO INDEMNIFY the Owners and Operators, LLP, Partner Organizations, and each of their respective divisions, parents, subsidiaries, wings, member organizations, affiliates, chapters, officers, directors, agents, employees, contractors, volunteers, insurers, heirs, assigns, and successors in interest, and any and all entities who referred us to LLP, from any and all claims, demands, liability (under the law of any state or country), fees, expenses, and costs of any kind whatsoever that I and any Minor(s) may have or claim to have on account of or in any way related to or arising from, directly or indirectly, the proposed and actual transportation, the cancellation or delay of the transportation, and/or the failure to provide return transportation.

    This release specifically includes, but is not limited to, any and all alleged negligent acts, errors, and omissions of any of the released persons or entities. In addition to economic damages, costs, and expenses, this release also specifically covers any and all injuries, deaths, and conditions of health, whether or not immediately apparent following the flight or transportation, or which may at any time thereafter develop.

    As evidenced by my signing this document, I regard the services, time, skills, flight, aircraft, transportation, vehicles, and other related costs and expenses being furnished to me and any Minor(s) as significant, material, and valuable consideration in exchange for this release.

    This release may be enforced by any person or organization released in this agreement. I agree that this document shall be governed and interpreted by the laws of the state of Illinois. Every term and provision of this release is intended to be severable. If any one or more of them is found to be unenforceable or invalid, that shall not affect the other terms and provisions, which shall remain binding and enforceable.

    I have read and understand this document. I talked with the Mission Coordinator or other persons associated with LLP about any questions concerning the proposed transportation. I understand that I had the right to obtain legal advice from an attorney of our choice prior to signing.

    By signing below, I acknowledge that this release is a contract with legal and binding consequences and I voluntarily provide my signature below. I assume all risks associated with the proposed transportation. If I am a parent or legal guardian to the Minor(s), I acknowledge that I am signing this on behalf of myself and the Minor(s).

  • *** Please check appropriate box for Minor (under 18 years of age) or Parent/Legal Guardian

    Click the (+) button to the right of the list to add more rows.

    Passenger Name (Actings as Signature if "Minor" not checked)DateMinorParent/Guardian 
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  • Please have all passengers (Parents/Guardians for Minors) sign in the same box below before submitting

  • By signing above, I also authorize LifeLine Pilots to use my name and photograph(s) in any report, media or for public relations purpose without compensation to me, unless the “NO” is checked here.

    By accepting this mission, I certify after review of relevant logbook entries that I meet the FAA regulations for a Flight Review (FAR 61.56) and recent flight experience which includes landing and night currency (FAR 61.57), as well as instrument experience or proficiency check (FAR 61.57(c)(d)) applicable to the accepted flight and aircraft to be flown. I further certify that the aircraft to be flown meets all applicable regulations and that the insurance coverage required by LifeLine Pilots will be in effect for each segment of the flight and I have the applicable medical certificate/class as required by FAR 61.23.