MCO P1100.73B.pdf - Marine Corps

SAMPLE
_____________________________ ________________
(Place - OSO Address) (Date)
(Concisely Give Time and Date of Scheduled Flight; Departure Point(s)
and Destination Point(s); Reason for Flight)
I (we)hereby execute and subscribe to the attached "Hold Harmless"
Agreement as the parent(s) or gaurdian(s) of (Full name and SSN of
minor passenger) and consent to their taking a flight(s) in certain
Marine Corps/Navy aircraft on the date(s) specified above; and whereas
they are doing so entirely upon themselves, and out own initiative,
risk and responsibility, now therefore, in consideration of the
permission extended to them and to us by the United States through its
officers and agents to take said heirs, executors, and administrators,
remise, release and forever discharge the Government of the United
States and all of its officers, agents and employees, acting officially
or otherwise, from any and all claims, demands, actions or causes of
action, on account of their deaths or any injury which may occur from
any cause during said flight(s) or continuances thereof, as well as all
ground and flight operations incident thereto.
Further, in consideration of the foregoing I (we) bind myself
(ourselves), or heirs, executors and administrators to hold harmless
the United SBtates of America for any injury which may occur from any
cause during said flight(s) of continuances thereof, as well as all
ground and flight operations incident thereto.
Further, in consideration of the foregoing I (we) bind myself
(ourselves), or heirs, executors and administrators to hold harmless
the United States of America for any action that may be brought at a
subsequent date by or on behalf or said flight(s).
_______________________________________________________________________
(Signature of Parent/Guardian) (Address)
_______________________________________________________________________
(Signature of Parent/Guardian) (Address)
_______________________________________________________________________
(Signature of Witness) (Signature of Witness)
Figure 2-40.--Parental Air Transportation Agreement for Minors (Hold
Harmless Agreement).
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