Name:__________________________________________________

Address:_________________________________________________

City: _____________________ State:__________________________

Home Phone:_____________________________ Cell Phone:_________________________________

E-Mail:_______________________________________________________

1a) Are you now or have you ever studied another martial art? Yes No

1b) If Yes, what styles and for how long?_________________________________________________

________________________________________________________________________________

2a) Do you have any Medical Conditions that we should be aware of? Yes No

2b) If Yes, please specify;____________________________________________________________

________________________________________________________________________________

Participant Signature:_____________________________ Date:____________________________

Signature of

Parent or Gaurdian:_____________________________ Date: ____________________________

IF UNDER 18 YEARS OF AGE THIS RELEASE AND CONSENT MUST ALSO BE SIGNED BY PARENT OR LEGAL GUARDIAN!

Please fill out BOTH forms!

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I-Liq Chuan

Workshop Release and Consent Form

I hereby assume all risk and responsibility for any and all damages, injuries or losses to my person or property, which I may sustain or incur in connection with my attendence at the I Liq Chuan workshop. I agree that any instructor or member of the I Liq Chuan workshop, promoters, operators and sponsors of the establishment (Arizona Shaolin Kenpo Academy), and their officers, agents or employees, shall not be responsible for any damages, injuries or losses to my person or property, which I may sustain or incur for any reason, cause or condition, whatsoever, including negligence, and I hereby release and discharge each and all of them individually or otherwise of and from all claim, demands, rights or cause of action whatsoever, which I or my heirs, executors, administrators or assigns have or may have against them or any of them by reason of matter or incident, whether arising from their negligence or otherwise, in connection with my attendenc eand participation at the I Liq Chuan workshop.

I agree with the use of my name, voice or photograph in connection with the actual conduction of any tournament and or event. In addition, in the event that any broadcast, telecast, taped, filmed or otherwise reproduced in any manner, I agree to the use of my appearance, in the I Liq Chuan workshop or any of it's function, as part of a broadcast or telecast (live, taped or rerun) or the exhibition of films of my participation, in the I Liq Chuan workshop or any of it's function, without any compensation to me.

I hereby consent to the participation of the minor, attending the I Liq Chuan workshop or any of it's aforementioned function, under the terms and conditions of this application, including the terms of release and covenant not to sue contained therein.

Participant Signature:_____________________________ Date:____________________________

Signature of

Parent or Gaurdian:_____________________________ Date: ____________________________

IF UNDER 18 YEARS OF AGE THIS RELEASE AND CONSENT MUST ALSO BE SIGNED BY PARENT OR LEGAL GUARDIAN!

Please fill out BOTH forms!

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