Great Wall Registration Form

Liability Release. For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I _______________, as parent or legal guardian of _________________, a minor (hereinafter "Minor"), hereby grant the permission necessary to allow Minor to participate in the above center to be conducted by Great Wall Enrichment Center Inc. (hereinafter the "CENTER").

I, in my own behalf and on behalf of Minor, further agree to release and to hold harmless CENTER, the Hosting site, on whose premises the Program will occur (hereinafter the "Location") the affiliates of CENTER, the Location, and the respective directors, officers, representatives, members, agents and employees of CENTER and their respective affiliates (hereinafter collectively "Releasees") from any and all liability whether caused by the negligence of the Releasees or otherwise for any claim, judgment, loss, liability, cost and expenses (including, without limitations, attorney's fees and costs) arising out of or connected with the Program, including any claim arising out of or connected with any illness or injury (minimal, serious, catastrophic and / or death) that Minor may incur or sustain during the Program, all activities associated with the Program and while traveling to and from the site for the Program whether or not the Program actually occurs.

I further expressly agree to indemnify and hold harmless Releasees and Releasees' heirs, successors, assigns, executors and administrators against loss from any further claims, demands or actions that may subsequently be brought by Minor or by any other persons on the account of damages of any character resulting to Minor in any way from the foregoing activities. I further agree to reimburse and to make good to Releasees any loss or costs Releasees may have to pay as a result of any such action, claim, or demand.

I, in my own behalf and on behalf of Minor, hereby warrant that I have read this Liability Release in its entirety and fully understand its contents. I, in my own behalf and on behalf of Minor, am aware that this Liability Release releases Releasees from liability and contains an acknowledgement of my voluntary and knowing assumption of the risk of injury or illness. I, in my own behalf and on behalf of Minor, further acknowledge that nothing in this Liability Release constitutes a guarantee that the Program will occur. I, in my own behalf and on behalf of Minor, have signed this document voluntarily and of my own free will.

Signature of Parent or Legal Guardian: X _______________________    Date: _______________

Medical Release. (Must select Part I or Part II) I, in my own behalf and on behalf of Minor, acknowledge and agree that such participation subjects Minor to possibility of physical illness or injury (minimal, serious, catastrophic and/ or death) and that I, in my own behalf and on behalf of Minor, acknowledge that Minor is assuming the risk of such illness or injury by participating in the program.

Part 1: In the event of such illness or injury, I ________________ DO authorize CENTER to obtain necessary medical treatment of Minor and hereby, in my own behalf and on behalf of Minor, release and hold harmless Releasees in the exercises of this authority. I further acknowledge and understand that I will be responsible for any and all medical and related bills that may be incurred on behalf of Minor for any illness or injury that Minor may sustain during the Program and while traveling to and from the site for the Program whether or not the Program actually occurs.

Part II: In the event of such illness or injury, I ________________ DO NOT authorize CENTER to obtain medical treatment of Minor. I authorize CENTER to take following actions: ___________________________.

Signature of Parent or Legal Guardian: X _______________________    Date: _______________

Appearance Agreement. I understand that CENTER from time to time produces promotional material relating to its programs. I understand that as a participant and/ or a spectator at the Center that Minor may be included in videotapes, photographs, DVDs, podcasts and videocasts taken during the Program. Therefore, without reservation or limitations, I, in my own behalf and on behalf of Minor, hereby assign, transfer and grant to CENTER, its successors, assignees, licensees, sponsors, any television networks, and all other commercial exhibitors the exclusive right to photograph and / or videotape Minor and to utilize such videotapes and photographs and Minor's name, face likeness, voice and appearance as a part of the Program, in advertising and promoting the Program or in advertising and promoting similar future events. I further understand that neither CENTER nor any third party is under any obligation to exercise any of the foregoing rights, licenses and privileges. I, in my own behalf and on behalf of the minor, waive any right to inspect or approve the copies of any promotional materials related thereto.

Center Rules. I further acknowledge and understand that CENTER has established rules and regulations pertaining to conduct, behavior and activities of all Program participants, by which Minor and I agree to abide during the Program, and that Minor and I will be responsible for his/her/my failure to abide by those rules and regulations. Minor and I have received, read and understand the Center rules. Minor and I understand that violation of the rules can result in dismissal from Program with no refund.

The CENTER staff wants students to have an excellent program experience. The rules listed below are for your protection and to insure a successful program for all participants. Any violation of these rules may result in dismissal from program without refund.
1. Students may not leave the center for the duration of program (except commuter students). Exceptions must be cleared in advance with the program director and have parental approval.
2. No use of alcohol or other illegal substances; there is no smoking at the center.
3. Please leave valuables at home. CENTER will not be responsible for lost or stolen items.
4. Any damage to the facility will be charged to responsible student.

Medical Insurance & Medication

Insurance Company: __________________________________________
Insurance Company Address: __________________________________________
Medical Insurance Policy Number: __________________________________________

I represent that any medication to which Minor is allergic or medications that Minor is currently taking are listed below. I agree that Minor shall bring medications which Minor is currently taking with him / her to the Center and that he / she shall consume the prescribed dosage for such medications.

CENTER will not administer or supply any type of medication at center.

Medications (if any): _____________________
Allergic to (if any): _____________________
I acknowledge that Minor suffers from the following conditions: _____________________
Family Doctor: _____________________
Phone Number: ( ) _____________________
Birth date: _____________________
SS#: _____________________
(not required but helpful for quick verification of insurance policy by hospital/clinic)
Emergency Information:
Name: _____________________
Address: _____________________
City, State, Zip: _____________________
Daytime Telephone: _____________________
Evening Telephone: _____________________

I, in my own behalf and on behalf of Minor, hereby warrant that I have read this Participant Release and Waiver Form in its entirety and fully understand its contents. I, in my own behalf and on behalf of Minor, am aware that this Participant Release and Waiver Form releases Releasees from liability and contains an acknowledgement of my voluntary and knowing assumption of the risk of injury or illness. I, in my own behalf and on behalf of Minor, further acknowledge that nothing in this Participant Release and Waiver Form constitutes a guarantee that the Program will occur. I, in my own behalf and on behalf of Minor, have signed this document voluntarily and of my own free will.

Signature of Parent or Legal Guardian: X _______________________    Date: _______________

Relationship to Minor: _______________________

For any questions, please call Ms. Xiaoxue Ma at 216-744-6008 or xiaoxue.ma@greatwallec.com. Download the file here, affter completing this form front and back, please email finished form to info@greatwallec.com. In addition, please print form and sign. Send signed form and tuition to us.