Taller Portobelo Norte: Congo Carnival Registration

2011 Taller Portobelo Norte African Diaspora at the Crossroad - Congo Carnival Trip Registration
March 6 - March 13, 2011

NOTE: You cannot save this form and finish it at a later date. You must fill it out completely and submit. You will receive a confirmation email once we have received and reviewed your registration.

Your full name

Mailing Address

Telephone Number Your email address

Date of Birth

Sex Male Female

Citizenship

How did you learn about the 2011 Taller Portobelo Norte Congo Carnival Trip?

Applicationt Health Statement:
To the applicant: A cultural immersion program can be both physically and emotionally stressful. Please provide an honest evaluation of your physical health by answering the following questions. If you answer “yes” to any of the following questions, please explain below, describing the details of the condition or treatment, including any medications taken.

Do you have any dietary restrictions or known food allergies?

Yes No

Do you have any physical disabilities or impairments that might cause hardship as a result of a change in diet, strenuous travel, or that might otherwise affect participation in a cultural immersion program?

Yes No

Are you currently being treated for any physical/mental conditions?

Yes No

Are you taking any medication?

Yes No

Are there any concerns relating to your health or your family's health history that we should know?

Yes No

Have you ever had any of the following?
A surgical operation (or have you been advised to have one?)

Yes No

Treatment in a hospital or mental institution?

Yes No

A major illness such as rheumatic fever or tuberculosis?

Yes No

Allergies to medication?

Yes No

Disorders not specified above, including eating disorders?

Yes No

Do you have any conditions that could affect your adjustment to a new culture or to a program abroad?

Yes No

Please explain any YES answers here:

AGREEMENT AND GENERAL RELEASE

1. In applying for my active participation in the Taller Portobelo Norte Congo Carnival Trip, I assure Taller Portobelo Norte that I am cognizant of all the inherent dangers related to international travel, as well as certify to Taller Portobelo Norte that I am physically fit to travel and will take all of the necessary precautions to ensure my own safety and well being and that there is no reason known to me for not being able to participate in the Taller Portobelo Norte Congo Carnival Trip.

2. I also hereby acknowledge that international travel carries with it certain risks. These risks include, but are not limited to, lost or stolen belongings, regional illnesses, motor vehicle accidents, bodily harm and/ or death. I certify that I will take all the necessary precautions to ensure my own safety.

3. I hereby agree that the Taller Portobelo its owners, officers, agents, supervisors, instructors, employees, successors and assigns may not be held liable in any way for any occurrence in connection with traveling, receiving instruction, any physical actions, or use of the facilities or equipment of the Taller which may result in injury, death or other damage to myself. In consideration for being permitted to engage in the Taller Portobelo Norte Congo Carnival Trip and the use of the facilities, I hereby release Taller Portobelo Norte, its owners, officers, agents, supervisors, instructors, employees, successors and assigns, from any and all causes of action, debts, controversies, and claims in connection with injuries, death or damage to myself, which I, my dependant, my heirs, executors, administrators, successors and assigns ever had, now have or hereafter may have. Furthermore, I do personally assume all risks in connection with the aforesaid use, for any harm, injury or damage which may befall me or my personal property while engaged in the use of the facilities, services or equipment, including all risk connected therewith, whether foreseen or unforeseen, and further save and hold harmless the said corporation and persons from any claims, including but not limited to any claims or liabilities arising out of the negligence of the aforesaid corporation, agents, offers, supervisors, instructors, emploees, successors and assigns, by me, my dependant, my family, estate, heirs or assigns.

5. I have read this document and I have received answers to any questions I might have about this document. I understand what I am signing and consent to these conditions. The provisions herein, when signed and accepted, shall constitute the entire agreement between us and cannot be changed, modified or dis- charged orally. This agreement shall remain in effect until I have actively ceased any activity with Taller Portobelo Norte and I have also given 30 days written notification of intent of being released from this waver.

6. In the event that I is involved in an unforeseen catastrophic medical accident, injury or illness, and I am incapable of making medical decisions regarding treatment, I grant Limited Power Of Attorney to whomever is in charge of the group at the time of the medical emergency. The sole purpose of the Limited Power Of Attorney is so that my immediate emergency medical needs may be met. I further agree to assume any and all medical expenses involved in my first aid or treatment should such a need arise.

Medical Waiver Signature

List at least 2 People to contact in case of an emergency. Please Provide their Names, Relationships to you and Phone Numbers.

Medical Insurance Company

Insurance Co. Phone Number

Insurance Policy ID Numbers

Authorization:
I certify that all information in this application is complete and accurate. I understand that Taller Portobelo Norte reserves the right to dismiss any applicant who does not meet the general behavior standards and that any applicant who is dismissed for any reason waives refund of all fees. Taller Portobelo Norte also reserves the right to cancel or revise the program as needed.

Authorization Signature Date of Authorization

Upon submitting this form you will be forwarded to the Online Payment Page. If you would like to make other payment arrangements, please submit this form, then click on Contact Us to email us regarding your payment.

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