KOREA TOUR 2006 - REGISTRATION FORM

KOREA SIMMUDO ASSOCATION
AND MARTIAL ART FITNESS CENTER, INC.

GENERAL INFORMATION

Full Name ________________________________________________________________

Address __________________________________________________________________

City ________________________________ State ________________ Zip _________

Country _____________________________

Phone _______________________________ Email ______________________________

Emergency Contact Name ___________________________________________________

Emergency Contact Phone __________________________________________________

Special Medical Conditions _______________________________________________

__________________________________________________________________________

WAIVER

Participants over age 18

I understand and agree that Fred Gommels, Pan Gon Song, Martial Art Fitness Centers Inc., Korea/USA Simmudo Association and its servants, agents and employees are released from any and all liability for me during this trip. I further understand that I shall be responsible for providing my own travel and health and insurance and in no way will its servants, agents and employees be held for responsible for any insurances of any kind.

I further agree and understand that during this tour, Fred Gommels, Pan Gon Song, Martial Art Fitness Centers Inc., Korea/USA Simmudo Association and its servants, agents and employees are released from any and all responsibilities for my own personal belongings or possessions that I may take.

I also waive any compensation in regards to any pictures or video furnished by me or taken of me in connection with this Trip, which might be used for publicity or promotion.

Print Name: ___________________________________________

Signature: ____________________________________________

For participants 17 and under

The undersigned certifies that he/she is the parent/legal guardian of the above listed participant, a minor. I also state that this participant has my permission to participate in the 2004 Korea Trip and all such activities thereof.

Its adult servants and agents and hereby given the authority to consent to any medical treatment that may be required for the participant with the same authority as myself. I also release its servants and agents, employees from any liability associated with this trip.

On behalf of the participant I also waive any compensation in regards to any pictures or video furnished of the participant in connection with this Korea Trip, which might be used for publicity or promotion.

I further agree to release its servants and agents form any and all responsibilities for the participant’s personal possessions or belongings, which may be brought with him/her.