1. Full Name (First and Last Name) *

2. E-mail *

3. Phone Number *

4. Age*

5. Allergies * ( or indicate none)

6. Additional Comments or Notes

7. Emergency Contact Name *

8. Emergency Contact Relationship to You

9. Emergency Contact Number*

10. Number of Children*

0 :

Capacity: Initial 40, Taken 0, Now 40

1 :

Capacity: Initial 10, Taken 0, Now 10

2 :

Capacity: Initial 8, Taken 0, Now 8

3 :

Capacity: Initial 5, Taken 0, Now 5

11. Child's First Name*

12. Child's Last Name*

13. Age

14. Child's First Name*

15. Child's Last Name*

16. Age

17. Child's First Name*

18. Child's Last Name*

19. Age

20. Allergies * ( or indicate none)

21. Additional Comments or Notes

22. How did you learn about Tzu Chi?*

Friends/Family

Social Media

Text Message

Other

23. I would like to be added to Tzu Chi Center's mailing list for newsletters and special events

WAIVER and CONSENT Language:

This Release and Waiver of Liability (the “Release”) releases the Buddhist Tzu Chi Foundation, a nonprofit organized and existing under the laws of the United States as a Section 501(c)(3) charitable organization, its affiliated entities, and each of its directors, officers, employees, and agents (hereinafter collectively referred to as “Tzu Chi”).

I (the “Participant”), the undersigned, give my consent to participate in all activities of Tzu Chi and desire to engage in activities related to serving or participating in Tzu Chi’s activities as a volunteer or participant. I understand that I am responsible for my own insurance coverage in the event of personal injury or illness as a result of participation in activities of Tzu Chi.

I do hereby freely, voluntarily, and without duress execute this Release under the following terms:

1. Waiver and Release: I hereby release and forever discharge and hold harmless Tzu Chi and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from the activities as a participant with Tzu Chi, including claims arising out of negligence. I understand and acknowledge that this Release discharges Tzu Chi from any liability or claim that I may have against Tzu Chi with respect to bodily injury, personal injury, illness, death, or property damage that may result from my involvement in Tzu Chi’s activities.
2. Insurance: I affirm that I am covered by primary medical insurance and understand that I am responsible for my medical bills if injury occurs. Further, I understand that Tzu Chi does not assume any responsibility for or obligation to provide me with financial or other assistance, including but not limited to medical, health or disability benefits or insurance of any nature in the event of my injury, illness, death or damage to my property. I expressly waive any such claim for compensation or liability on the part of Tzu Chi beyond what may be offered freely by Tzu Chi in such events.
3. Assumption of Risk: I understand that the activities provided by Tzu Chi and in which I am involved may include activities that are inherently dangerous to me. I hereby expressly assume the risk of injury or harm to myself from these activities and release Tzu Chi from all liability for injury, illness, death, or property damage resulting from these activities.
4. Photographic Release: I grant and convey to Tzu Chi all right, title, and interest in any and all photographs, images, video or audio recordings of my likeness or voice made by Tzu Chi in connection with my involvement in Tzu Chi’s events, including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
5. Medical Treatment: I hereby release and forever discharge Tzu Chi from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my participation in Tzu Chi’s activities. I give my consent for Tzu Chi to provide, administer, or obtain medical treatment for me.
6. Other: I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of New York and that this Release shall be governed by and interpreted in accordance with the laws of New York. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

I have read and consent to enter into this Release and Waiver of Liability knowingly and voluntarily. I agree to sign this waiver form electronically. *

Media Release Consent

I hereby give Buddhist Tzu Chi Foundation (“Tzu Chi”) and its affiliates and authorized partners the right and permission to use, reproduce, publish, transmit, distribute and display photographs or video, in whole or in part, of me for use in Tzu Chi’s newsletter, magazine, annual/periodical report, promotional or educational materials, web site or public media which include catalogs, brochures, posters, magazines, articles, CD-ROM, DVD, electronics newsletters and Tzu Chi’s internet web site. I recognize that Tzu Chi is a nonprofit public charity organization which does not make profits, and I waive any claim for payment for the use of my photograph by Tzu Chi. I further waive any right to inspect or approve the finished photographs, images or printed matter that may be used in conjunction therewith or to the eventual use that might be applied.

By completing this form, I acknowledge that I received and give my consent to the the waiver above *

Signature *