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学生信息 Student's Information
身份证姓名 Full Name (matching your ID)
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绰号 Apelido
电话 Phone
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微信ID Wechat ID
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邮箱 Email
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国籍 Nationality
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身份证、护照号 Passport Number or Chinese ID
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紧急联系人信息 Emergency Contact Information
紧急联系人身份证姓名 (同证件号) Emergency Contact Full Name (matching the ID)
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紧急联系人语言 Emergency Contact Preferred Language
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同本人关系 Relationship to the person (family, friend, etc.)
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紧急联系人微信 Emergency Contact Wechat ID
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紧急联系人联系电话 Emergency Contact Contact Phone
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联系邮箱 Emergency Contact Email address
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Checkboxes
I have want to add an overseas Emergency Contact information
Overseas Emergency Contact Full Name (matching the ID)
Overseas Emergency Contact Country / Timezone
Overseas Emergency Contact Preferred Language
Overseas Emergency Contact Contact Phone
Overseas Emergency Contact Email address
医疗信息 Medical Form
血型 Blood type
疾病史 (若有，请描述) Pre-existing medical conditions (if any, please specify below)
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药物和其他过敏史 Medicine and other Allergies
糖尿病 Diabetes
高血压 High blood pressure
低血压 Low blood pressure
癫痫 Epilepsy / Seizures
骨折 Broken Bones
手术史 Recent Surgery
心脏病 Heart disease
肺部疾病 Lung disease
肺炎 Pneumonia
哮喘 Asthma
脑中风 Stroke
胸痛 Chest Pains
晕厥 Fainting
其他 None of the above
其他未列明的疾病史、药物史 Additional Medical Notes
紧急情况下的医院名称医疗保险号 Preferred Hospital to be taken to, Medical Insurance Policy Number etc.
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风险承担和责任免除申明
(English below)
我在此承担参与 Capoeira Maloca Shanghai 活动的所有风险，包括并不限于任何因为个人或实体的疏忽或粗心、危险所造成的风险，或者由于她们拥有、保养的造成危险、有缺陷的设备，或由于他们可能承担的无过错责任。 我证明我身体健康，并且没有被合格的医疗专业人员建议不得参加。本人证明，不存在妨碍本人参加上海马跃卡巴西战舞活动的健康相关原因或问题。我承认此事故豁免和责任免除表将可能由我参加上海马跃卡巴西战舞的组织者使用，并将约束我的行为和责任。 考虑到我的申请并允许我参加 Capoeira Maloca Shanghai 活动，我特此为自己、我的遗嘱执行人、管理人、继承人、直系亲属、继任者和受让人采取如下行动： (A) 我放弃、免除和免除任何和所有责任，包括但不限于因人员或团体的疏忽或过失而导致的死亡、残疾、人身伤害、财产损失、财产盗窃的责任，或我此后可能发生的任何类型的行为，包括我往返于上海马跃卡巴西战舞的活动。以下团体或人员：Capoeira Maloca Shanghai、上海好打图库文化传播有限公司、Nicolas USE、Tatiana Maria Fisher Ortiz，和/或其教练、代理人、代表或志愿者。 (B) 本人放弃对所述团体或个人因参与上海巴西战舞马跃卡团队活动而产生的任何及所有责任或索赔（无论是由于疏忽或其他原因造成的），并承诺不对其提起诉讼。 我承认上海巴西战舞马跃卡活动可能会带来死亡、重伤和个人损失。风险可能包括但不限于由地形、设施、温度、天气、参与者的条件、其他人的行为（包括但不限于参与者、志愿者、观众、教练和缺乏水分）引起的风险。 我同意上海巴西战舞马跃卡和/或他们的教练、代理人、代表或志愿者可以在活动期间拍摄我作为参与者的照片或数字录音，并在任何和所有媒体中使用这些用于培训或宣传目的。我进一步同意我的身份可能会在其中或通过描述文本或评论透露。我放弃任何相关权利或利益，并且我明白不会有任何经济或其他报酬。 事故豁免、责任免除和图像发布应被广泛解释为在适用法律允许的最大范围内提供免责声明和豁免。 我保证我已经阅读了本文档，并且我完全理解它的内容。我知道这是免责声明和合同，我是自愿签署的。
ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM
I hereby assume all of the risks of participating in Capoeira Maloca Shanghai activities, Including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them, or because of their possible liability without fault. I certify that I am physically fit and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in Capoeira Maloca Shanghai activities. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the organizers of Capoeira Maloca Shanghai in which I may participate and that it will govern my actions and responsibilities. In consideration of my application and permitting me to participate in Capoeira Maloca Shanghai activities, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A)I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from Capoeira Maloca Shanghai activities. THE FOLLOWING ENTITIES OR PERSONS: Capoeira Maloca Shanghai, 上海好打图库文化传播有限公司, Nicolas USE, Tatiana Maria Fisher Ortiz, and/or their coaches, agents, representatives or volunteers. (B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in Capoeira Maloca Shanghai activities, whether caused by negligence or otherwise. I acknowledge that Capoeira Maloca Shanghai activities may carry with it the potential for death, serious injury, and personal loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, and lack of hydration. I consent and agree that Capoeira Maloca Shanghai, and/or their coaches, agents, representatives or volunteers may take photographs or digital recordings of me as a participant during events and use these in any and all media for training or promotional purposes. I further consent that my identity may be revealed therein or by description text or commentary. I waive any rights, claims or interest and I understand that there will be no financial or other remuneration. The accident waiver, release of liability and image release shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT ON MY OWN FREE WILL.
参与者的姓名 Participant’s Name
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参与者年龄 Participant’s Age
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未成年人的父母/监护人豁免（18 岁以下）
下面签名的父母和/或自然监护人特此声明，他/她实际上以此类身份行事，已同意其子女或受监护人参加上海马跃卡巴西战舞活动，并代表子女或受监护人单独同意，根据上述事故豁免和责任免除条款，签名的父母或监护人进一步同意免除上述各方的责任、损失、成本、索赔或损害，并免除赔偿上述各方因缺乏此类能力的任何缺陷而可能遭受的任何责任、损失、成本、索赔或损害。
PARENT/GUARDIAN WAIVER FOR MINORS (under 18 years old)
The Undersigned parent and or natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward’s participation in Capoeira Maloca Shanghai activities, and has agreed individually and on behalf of the child or ward, to the terms of the accident waiver and release of liability set forth above. The undersigned parent or guardian further agrees to save and hold harmless and indemnify each and all parties referred to above from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon said parties because of any defect on lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.
下载、阅读并条款和条件 Download, Read the Terms and Conditions
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签名（如果未满 18 岁，父母或监护人必须签名）Signature (if under 18 years Parent or Guardian must sign)
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日期 Date
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本表和个人信息复印件仅供上海巴西战舞马跃卡团队内部使用，不得与任何其他方共享。此信息仅在紧急情况下使用。
This form and copy of personal ID is for internal use only by Capoeira Maloca Shanghai Team and will not be shared with any other parties. This information will only be used in case of an emergency.
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