2006 Junior Leadership Seminars

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Registration Form

Last Name: ________________ First/Middle: ______________________

Chinese Name:____________________ (if applicable)

Date of Birth: ______(Month)/______(Day)/_______(Year)

Sex: ___________ Lunch: Meat ______ or Veg. _____

Address: ________________________________________________________

Phone No.: ____________________

Email Address: _____________________________

School: ___________________________________

Grade: _______________________

Father’s Name: ______________________(English)

______________________(Chinese, if applicable)

Mother’s Name: ______________________( English)

______________________(Chinese, if applicable)

Please Sign the following Liability Form

All reasonable precautions will be taken to prevent accidents in these programs. However, 2004 Junior Leadership Seminar sponsors, their agents, lecturers, volunteers and affiliating companies and organizations shall not be liable for injuries while participating in these programs. I assume all responsibilities and compensation for any accidental injury or damage incurred by my minor child or myself.

Signature of Guardian: ; Date:

(Under 18 signature required)

Signature of Participant: ; Date:

Signature(s) is Required for Participation