I am applying for the following available course dates:

NAME:

LAST:

FIRST:

MIDDLE:

DATE OF BIRTH:
(Month/Day/Year - 00/00/0000)
/ /

E - MAIL ADDRESS:

ADDRESS:

CITY / TOWN:

STATE:

PROVINCE:

ZIP CODE:

COUNTRY:

PHONE #'s:

HOME:
- -

CELL:
- -

WORK:
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FAX:
- -

OCCUPATION:

How did you learn about the THE HUMAN NATURE INSTITUTE, NATURAL DUTIES?

HEALTH & EMERGENCY INFORMATION

NAME OF EMERGENCY CONTACT:

LAST:

FIRST:

FULL ADDRESS OF EMERGENCY CONTACT:

PHONE #'s OF EMERGENCY CONTACT:

HOME:
- -

CELL:
- -

WORK:
- -

RELATIONSHIP WITH EMERGENCY CONTACT:

ANY DIETARY OR ALLERGY CONCERNS:

ANY PERTINENT MEDICAL CONDITIONS, INFORMATION
AND MEDICATIONS WE NEED TO BE AWARE OF:
(In other words, if something happens to you,
what would you want us to know about your medical history.)

RELEASE WAIVER

In all workshops, classes, demonstrations, and excursions conducted by JOSEPH LAU, THE HUMAN NATURE INSTITUTE, NATURAL DUTIES, and Joseph Lau, individually, and all agents, contractors and assistants; reasonable care is taken to prevent serious injuries and to minimize accidents.

The PARTICIPANT states that he/she is fully aware that martial art skills, wilderness skills, healing skills and awareness skills training, even under the safest conditions possible may be dangerous, and the PARTICIPANT hereby agrees to accept full responsibility and assume all risks, including those caused by acts of God, injury, death, and/or loss to his/her person and/or property knowingly and voluntarily.

The PARTICIPANT agrees to obey the rules and regulations that JOSEPH LAU, THE HUMAN NATURE INSTITUTE, NATURAL DUTIES puts into effect to minimize these risks. Especially included rules and regulations are that should such training periods incorporate free sparring and/or contact of any kind, ALL PARTICIPANTS will be wearing the following: headgear, mouthpieces, padded kicking boots, groin cups (for males) and chest/breast protectors (for females.)

The PARTICIPANT knowingly, voluntarily, and irrevocably waives any and all past, present, and/or future injuries, death, or loss including those caused by acts of God, received while participating in activities conducted by JOSEPH LAU, THE HUMAN NATURE INSTITUTE, NATURAL DUTIES as a participant, student, spectator, and/or visitor, or in any other manner or form, taking part in the exercises, practices, excursions, and/or demonstrations of said martial art skills, wilderness skills, healing skills and awareness skills training.

The PARTICIPANT certifies that he/she is physically capable to participate in the said training program despite the rigors an dangers inherent in such an undertaking.

The PARTICIPANT accepts all responsibility for any injury, death, and/or loss to his/her person or property, including by acts of God, for the rigors and dangers inherent in this undertaking

The PARTICIPANT releases to JOSEPH LAU, THE HUMAN NATURE INSTITUTE,, NATURAL DUTIES the rights to use any photograph, video and or audio recording taken while participating in said martial art skills, wilderness skills, healing skills and awareness skills training, to be used as deemed by JOSEPH LAU, THE HUMAN NATURE INSTITUTE, NATURAL DUTIES, including advertising.

The PARTICIPANT also acknowledges that should the PARTICIPANT cancel after two weeks before the starting class date his/her full deposit will be refunded minus a Fifty Dollar administrative fee.

MY NAME WRITTEN IN THE TEXTFIELD BELOW
INDICATES MY ACCEPTANCE
OF ALL OF THESE ABOVE TERMS
and my desire to PARTICIPATE
with JOSEPH LAU, THE HUMAN NATURE INSTITUTE, NATURAL DUTIES.

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SEMINAR PAYMENT INFORMATION

 

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I will be sending a

CHECK

MONEY ORDER

OR CREDIT CARD:

PLEASE CHARGE ME. Check me.

PLEASE NOTE:
You will soon be sent a request to submit your payment to pay through
PAYPAL as I have discontinued my merchant credit card charging account.

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Please allow 2 weeks to receive confirmation
and follow up information.

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Click SUBMIT only ONCE please.