Zentherapy(R) Seminar
July 30 - August 1, 2010
ONLINE REGISTRATION FORM
Please provide the following demographic information about you (seminar participant):
Name:
Company/School:
Address:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:
Would you like to receive updates about future events by email?
Please provide an emergency contact:
Emergency Contact Name:
Relationship:
Address:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:
Do you (or participant, if different) have any medical conditions for which our instructors should be sensitive to? If so, please describe.
Please describe any dietary preferences or restrictions.
Participant’s Waiver and Release:
I hereby assume all of the risks of participating and/or volunteering in this activity or event, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them, or because of their possible liability without fault. I certify that I am physically fit, have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event. By agreeing to this waiver, I take full responsibility and waive all claims of personal injury, death and damage to personal property while participating in any activities, functions associated with the Institute of Zen Studies. I certify that I have read this and fully understand this contract. I am aware that this is a release of liability and a contract and I agree to it of my own free will.
