(This form must be signed, dated and returned with your registration form and payment)

Event:  Winterlude "Orlando Style", February 14, 2002 through February 18, 2002

First Name: _____________________________ Last Name: _____________________________   

Address: __________________________________________ Apt. #__________

City   __________________________ State/Prov. ______________________ Zip ____________
                                                                                 

                                                          RELEASE OF LIABILITY
By signing below, I acknowledge that all activities sponsored or conducted by the Mosaic Club of Central Florida may be hazardous, and may result in personal injury, loss, damage, or death and I am voluntarily participating in these activities with knowledge of the dangers involved and assume any and all risks of injury, damage or death.   With full knowledge of these dangers, I hereby agree for myself, and all of my family and heirs, to RELEASE Mosaic of Central Florida, representatives, event leaders, volunteers, officers, directors, members, or agents, from any and all liability, claims, or any causes of action, and not to sue or otherwise make any claim against Mosaic, or any of its chapters, groups, representatives, event leaders, officers, directors, members, or agents which may arise during my participation in any Mosaic Winterlude "Orlando Style" 2002 activities.

I intend this RELEASE OF LIABILITY to be effective whether or not any loss, damage, injury, or death RESULTS FROM NEGLIGENCE of Mosaic or any of its agents, leaders, instructors, volunteers, guides, event leaders, officers, directors, members, or representatives.  I understand that negligence means a failure to act in a reasonably prudent manner under the same or similar circumstances, in order to protect oneself or others from injury, loss, or death.

I agree to be solely responsible for my own safety and to take every precaution to provide for my own safety and well-being while participating in activities of Mosaic. 

I have read and agree to all of the above.  I sign this of my own free will and am not under the   influence of alcohol, drugs, or narcotics.


Signature________________________________________Date___________________