Student Name:

Address:

In case of emergency notify

Name:		Phone:		Relationship:
Name:		Phone:		Relationship:

Medical Insurance

Insurance Company:		Group ID Number:
Member Name:		Member ID Number:

I wish to participate in the above workshop organized by the Feng Yun Go School, which in addition to playing the game of go and receiving instruction about go, may include physical activities such as kung fu, tai chi, and other martial arts exercises supervised by Shaolin Kung Fu & Tai Chi instructors. I am aware of the risks inherent in participating in these activities, including physical injury, and 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 pertaining to any such activities. I agree to allow any medical personnel to treat any illness, injury, or any other medical condition that may occur during the workshop. I agree to accept responsibility for any medical costs that 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 this workshop.

In consideration of and part of a right to participate in this workshop, I hereby release and indemnify the Feng Yun Go School and Shaolin Kung Fu & Tai Chi and 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 workshop.

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.

Signature: __________________________________________________  Dated: ____________

A parent or legal guardian must sign for participants under 18 years of age, thereby consenting to this minor participating in the workshop.

Parent/Guardian Full Name: