Feng Yun Summer Go Workshop
Days Inn Hotel
Parsippany, New Jersey
August 20-24, 2012
Participant Full Name: _____________________________________
Birth Date: _____________ Gender: M F
Medical Insurance Carrier: ___________________________ Policy #: __________________
In case of emergency notify:
1. Name: ______________________________ Phone: _______________ Relationship: _________
2. Name: ______________________________ Phone: _______________ Relationship: _________
I wish to participate in the above Feng Yun Go Workshop organized by the Feng Yun Go School, which in addition to playing the game of go and receiving instruction about go, may include optional physical activities such as walking outdoors, tennis, soccer, swimming, bowling, and miniature golf, and transportation to and from these activities. I am aware of the special dangers and risks inherent in participating in these activities, including physical injury, death, or other consequences arising or resulting from these activities. I agree to accept responsibility for such risks. I further agree to advise activity planners of any physical or mental limitations that I may have that pertain to any such activities. I agree to allow any medical personnel the opportunity to treat an illness, injury, or any other medical condition. I agree to accept responsibility for any medical costs which may result from my participation.
I agree to be fully responsible for my own property, and for the care of any equipment and facilities related to the Feng Yun Summer Workshop.
In consideration of and part of a right to participate in the Feng Yun Go Workshop, I hereby release and indemnify the Feng Yun Go School all their associates and their staff of any and all liability, claims and causes of actions arising out of or in any way connected with my participation in this activity offered by the Feng Yun Go School.
I have read this release and indemnification agreement and understand its meaning. This release is intended to bind my heirs, representatives, successors, assignees and administrators.
If the participant is under 18 years of age then, being fully informed as to these risks, I hereby consent to this minor participating in the Feng Yun Summer Workshop.
Parent or legal guardian must sign for participants under 18 years of age.
Parent/Guardian Full Name: _____________________________________