My FOCUS WILL BE ON:
dance ……………. percussion ……………
NAME:
……………………………………………………………………………………
Last First MI
ADDRESS: …………….………………………………………………………….
Street
..................…………………………. ……………….
………………
City State Zip Code
HOME PHONE: ………………………….
WORK PHONE: ………………………
E-MAIL: …………………………………..
FAX NUMBER: ………………………
DATE of BIRTH: …………………………
PASSPORT#: ……………………………..
EXPIRATION DATE ………………...
EMERGENCY CONTACT: ……………………………
……………………………..
Name relationship
…………………………… ……………………………..
Home phone Work phone
Are you allergic to any medication or do you have a medical
condition you believe we should be aware of?
………….. ……………
…………………………………………………………
Yes* No *If yes, please explain
PAYMENT INCLUDED:
total fee …………………..
non-refundable
deposit …………………..
balance due …………………..
AGREEMENT: By signing this application form, you agree to the liability
terms stated on the included liability agreement. You also agree that the total
amount is due no later than Apr. 25, 2003. If, for any reason, you decide to
cancel after this date, the Rumba y Folklor program will retain $500. In
case of a cancellation after May 9th, 2003 the program will retain
the 100% of the full amount of the payment.
Signature …………………………………………………….
Date: …………….
RUMBA y FOLKLORE
in Matanzas, Cuba
May 17 – 31, 2003
LIMITS OF LIABILITY / CANCELLATION POLICY
Please sign and return with your registration. Please read the following
information carefully
in order to understand the limits of the service provided to you. Please make a
copy of this document for your records.
I, ………………………………………, will be
attending the Rumba y Folklore Program at the University of Matanzas,
Cuba from May 17 to May 31, 2003. I hereby agree to assume all risks in
connection with my attendance and participation in the Rumba y Folklore
Program and agree to release its organizers from any and all liabilities and
claims whatsoever arising in connection with my attendance and participation in
the program.
I understand that I am responsible for arranging, obtaining and securing all
travel arrangements to and from Montreal or other, previously agreed upon, point
of departure. I further understand that the organizers of the Rumba y
Folklore Program in Matanzas has made no representation concerning the
safety of the methods of travel to and from the travel sites visited and thus,
assumes no liability for injury, delay, irregularity, loss or damage to person
or property or additional costs resulting directly or indirectly from: acts of
nature, detention, weather, failure of any means of transportation to comply
with schedules, quarantines, strikes, civil and military disturbances, theft,
government regulations related to customs, immigration, violations of law, or
trade embargoes, discrepancies and/or change in transit or living accommodations
over which it has no control, whether it arises out of or is incident to the
program or otherwise. I understand that reasonable changes in schedule or prices
may be made at any time when deemed advisable for the comfort and well being of
the participants.
I understand that Rumba y Folklore Program cannot accept any
responsibility for the property of or personal illnesses of or injuries to any
program participants during the program. Furthermore I consent to and authorize
emergency and non-emergency care to be provided to me and/or my child in the
event of a health problem or injury occuring during the attendance of the
aforementioned activity.
I understand that Rumba y Folklore Program reserves the right to refuse
to accept or retain me as a program participant.
Cancellation policy
I understand that for cancellations made after April 25th, 2003 the Rumba
y Folklor Program will retain the portion of $500 of the program fee.
I understand that for cancellations made after May 9th, 2003 one hundred percent
(100%) of the program fee will be retained by Rumba y Folklore Program.
I affirm that I have read and understood this document and agree to the terms
stated above.
Signature: ……………………………………..
Print name: ……………………………………..
Date: …………………………………….
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