Consent Form

同　意　書

CONSENT AND RELEASE

1、我聲明對於菩提中心於　　 　 月份舉辦的　　　　靜修所規定的住宿規則、費用、程序、應負的責任，及可能發生的意外事項與後果，均充分了解，並且願意遵守合作。

I CERTIFY AND ACKNOWLEDGE THAT I have had the opportunity to fully read the Camp Rules of American Bodhi Center’s  day Retreat (hereinafter to as “Retreat”), I HEREBY AGREE TO abide by the said rules. As a Retreat participant, I FULLY AWARE OF its cost, risks, obligations, procedures, benefits and consequences.

2、靜修期間，如果有身體不適、受傷或無法自我照顧等事項發生時，我願意授權給靜修會的承辦人員為我做合理與必要的緊急醫療措施。事後我與家人決定不會對菩提中心及其人員做任何形式的控訴。

I AUTHORIZE the staff and/or agents of the Retreat to provide to, obtain, designate, or authorize any reasonable and necessary medical treatment and/or emergency care for me, in the event of my illness, injury or incapacity. I AGREE TO release and forever discharge, indemnify and hold harmless the American Bodhi Center, and/or agents from any claim by myself or my family members arising out of the said illness, injury or incapacity.

3、我了解於靜修期間，在菩提中心或其他任何醫療機構所接受的合理與必要的診治，其費用均由我本人負責。我的保險公司是　　　　　　　，我的保險卡號碼是　　　　　　　。

I UNDERSTAND THAT I will be responsible for any and all charges or fees for the medical treatment, provided either at the American Bodhi Center or at any other medical facilities, deemed reasonable and necessary by the staff and/or agents of the Retreat.  My medical insurance company is             , and my policy number is      .

4、在參加靜修期間，如果有任何形式的損失與傷害，我願不對菩提中心、有關合作單位及其職員與義工，做任何形式的控訴、要求與傷害，在此我願簽名作證。

BY PLACING MY SIGNATURE BELOW, I HEREBY IRREVOCABLY COVENANT, PROMISE AND AGREE TO release and forever discharge, indemnify and hold harmless the American Bodhi Center, any affiliated entities, and all of its officers, members, employees, agents, volunteers, and/or servants form and against any and all losses, claims, expensed, suits, costs, demands, damages or liabilities, joint or several, of whatever kind or nature, arising out of or in connection with my attendance and participation in the Retreat.

簽名/Signature        日期/Date