Name___________________________________ Date of Birth________________

Address_________________________ Occupation_________________________

Home Phone_______________Work Phone___________ E-mail______________

Class you are taking & Location_________________________________________

Please make checks payable to chinese wushu & tai-chi academy. (no refunds/12 week commitment)

Voluntary Release and Waiver

In consideration for being permitted by Chinese Wushu & Tai-Chi Academy to participate in Tai-chi/Wushu I ______________________(print name), for myself, my spouse, heirs, legal representatives and assigns, hereby assume all risks for such involvement, and release and discharge the Chinese Wushu & Tai-chi Academy, its affiliates, agents, officers, and employees, from all liability, claims, demands, actions and causes of action whatsoever, whether known or unknown, arising out of or relating to any loss or damage that may occur either directly or indirectly from my participation in such activity.

I enter into this VOLUNTARY RELEASE & WAIVER willingly and with full knowledge and understanding that by my signature below, I am expressly releasing the Chinese Wushu & Tai-chi Academy's facilities and equipment or engaging in the Academy's Tai-chi and Wushu activity.

Student Signature_________________________________ Date_____________

Signature of Parent or Legal Guardian Required if Student Is Under 18 Years of Age