Shaolin Kung Fu Program

Shaolin Kung Fu Program at

飛揚藝術中心

CPAA Arts Center

6148 Bollinger road, San #2072, Jose, CA 95129 10123 N. Wolfe Road Cupertino, CA 95014

www.ShaolinINT.com/www.cpaaartscenter.com • Tel/Fax: (408) 973-8276 • Email: [email protected]

Class Registration Form 少林功夫課程報名表 Student Name 學生姓名: _____________________________________________ Date of Birth 出生日期: _______________ English 英文

Chinese 中文

For Youth Ony 十八歲以下: __________________________________________________________________________ Guardian’s English Name 監護人英文姓名

Guardian’s Chinese Name 監護人中文姓名

Address 地址: _____________________________________________________ Email 電郵: _____________________ Phone 電話: Home 住宅: __________________ Program 課 程: ____ 3 months 三個月

Work 辦公室:__________________ Cell 手機: ____________________

____ 6 months 六個月

____ 1 year 一年

____ 2 years 兩年

____ 3 years 三年

Number of classes/week 每週上課次數:_________________ Class Schedcule上課時間: Class 1 第一課: __________ Day 星期 _____ Time 時間 _____ ; Class 2 第二課: __________ Day 星期 _____ Time 時間 _____ Class 3 第三課: __________ Day 星期 _____ Time 時間 _____ ; Class 4 第四課: __________ Day 星期 _____ Time 時間 _____ Payment/Donation 付款/捐款: $ _________ with Check # 支票號碼 $ _________ with Check # 支票號碼 $ _________ with Check # 支票號碼 $ _________ with Check # 支票號碼 $ _________ with Check # 支票號碼 $ _________ with Check # 支票號碼

___________From 上課日期由_________ to 至_________ Total classes 共________ ___________From 上課日期由_________ to 至_________ Total classes 共________ ___________From 上課日期由_________ to 至_________ Total classes 共________ ___________From 上課日期由_________ to 至_________ Total classes 共________ ___________From 上課日期由_________ to 至_________ Total classes 共________ ___________From 上課日期由_________ to 至_________ Total classes 共________

課 課 課 課 課 課

Registration Fee 報名費: $50 Pay by credit card 信用卡付款: Card No. 信用卡號碼___________________________ Expiration Date 有效日期至: _____________

Waiver and Release Agreement I hereby acknowledge and agree that: (i) there are risks inherent in participating in activities associated with Shaolin Temple USA, Chinese Performing Artists of America, or CPAA Arts Center (the “Activities”); and (ii) in order for me or my children to be allowed to participate in the Activities, I give up my rights to hold Shaolin Temple USA, Chinese Performing Artists of America, or CPAA Arts Center and its employees, agents, officers, directors, shareholders, officers, and instructors (the “Covered Entities”) liable for any injury or damage that I or my children may suffer while participating in the Activities; (iii) this Waiver and Release Agreement (the “Agreement”) will release, discharge, waive and forever relinquish any and all actions, causes of action and claims that I or my children have, may have or have had, whether past, present or future, whether known or unknown, and whether anticipated or unanticipated by me, arising out of participation in the Activities; and (iv) by signing this Agreement, I am assuming full responsibility for any and all risk while participating in the Activities. Knowing this, and in consideration of me or my children being permitted to participate in the Activities, I hereby release each of the Covered Entities from and against any and all liability resulting from or arising out of my or my child’s participation in the Activities. By entering into this Agreement, I am not relying on any oral or written representation or statements made by any person, other than what is set forth in this Agreement. I agree that this Agreement shall be governed by and interpreted in accordance with the laws of the State of California, U.S.A., without regard to any conflict of law principles. If any provision of this Agreement is unenforceable or invalid, the affected provision shall be severed. The remainder of this Agreement will then be construed as though the unenforceable or invalid provision had not been contained herein. I hereby declare that I am the legal guardian of the student. I have read this agreement, understand it and agree to be bound to it as a contract.

Printed Name 姓名（請用正楷填寫): ___________________________ Signature 簽名: _____________________ Class Starting Date 開課日期: ________________ Today’s Date 今天日期: ___________________ 070808