Participant Name (last) __________________________(first)_________________

Phone _____________________ Emer. Phone ____________________________

� Male � Female Birth Date ____/____/____

Address____________________________________________________________

School Name & Location ________________________ Grade ________________

List any specific health problems, allergies or medications___________________

___________________________________________________________________

E-mail address ______________________________________________________

(Your E-mail address will be kept confidential. Please print clearly since it is our way to communicate about the program with you)

WAIVER OF LINGUATAAL INTERNATIONAL, INC. LIABILITY
The participant or parent/guardian of the above named child, who participates in programs organized by Linguataal International, Inc. assume all risks and hazards incidental to the conduct of the activity and transportation to and from the activity. I am aware that participating in any program can be a dangerous activity involving many risks of injury. Participation is at my/my child's own risk. I do further release, absolve, indemnify and waive any claims against Linguataal International, Inc., its organizers, instructors, sponsors and any supervisors appointed by them, etc. There is no medical coverage.

Signature_______________________________________________Date_____________________

Make Checks Payable to: Linguataal

Mailing address: Linguataal; P.O. Box 3205; Newtown, CT 06470

Refund Policy: We will be happy to give refunds minus a $10 registration Fee, only if notification is received one week (7 days) prior to the start of the program. No refunds will be given once the program begins. No exceptions!

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