November 8, 2008

Medical Release Form

I / We do hereby give Tae Zee Park, Rick Warren, Mark Good, Robert Barss and / or any other Master Instructor permission to seek medical attention as needed for the participant named below.

I / We agree to not hold Tae Zee Park, Rick Warren, Mark Good, Robert Barss or any other Master Instructor liable for any accident or injury that may occur, and release them from their own negligence.

I understand that Tae Kwon Do is a contact sport.

Participant’s Name: ___________________________________________________

Emergency Phone number: (_____)-_____-____________ Relationship:__________

Emergency Phone number: (_____)-______-____________ Relationship:__________

Health Insurance Company:_______________________________________________

Policy Number:__________________________________________________________

Signature

Participant/ Parent or Legal Guardian (if under 18yrs. of age)

_________________________________________ Date: ______________