Contact __________________________________________________________ Address __________________________________________________________ _________________________________________________________________ City ________________________________ | State/Province ________________ Country _________ | Post Code ____________ | E-mail ____________________ Phone (Home) ___________________ | ( ____ /Work/Fax) ______________________ HVC Use Reg Form 11/1/96 __/__/__ z______ z______ z______ _______ Comments: Hawaii's Volcano Circus RR2 Box 4524 - Pahoa, Hawaii 96778 (808) 965-8756 ASSUMPTION OF RISK AND RELEASE OF LIABILITY In case of medical emergency, I authorize the representatives of H.V.C. to take me (or any of my dependents) to a medical facility and I authorize any care and treatment deemed necessary by a doctor at such facility. I, the undersigned, on my own behalf and our successors in interest, in consideration of the receipt of permission and license to enter onto the premises, vehicles and facilities and to participate in the activities of H.V.C., and their agents, representatives, and/or employees, during the period stated below. I fully recognize the dangers and hazards inherent the activities (as well as transportation to and from such activities) in which I may choose to particiapte, and I hereby agree that I will not sue H.V.C., their employees, representatives, members, owners, leasees or leasors, for any injury to any persons or property sustained during the course of such activities. I furthermore agree to assume all responsibility surrounding participation in H.V.C.'s activities and hold harmless, indemnify and release H.V.C. and Village Green Society, their officers, board members and associates from and against any and all claims, demands and actions which may result in the damage to personal property, personal injury, or death. In the event of the default of this agreement by myself or my successors, liquidated damages shall be equal to any judgement rendered against H V.C. and Village Green Society, and all their officers, representatives, employees and associates. I have read the preceding agreement and agree to all the terms outlined above for me, my family and group. My participation in such activities during the Hawaiian Juggling Festival will extend from Feb. 9 until Feb. 16, 1997. 1) 2) 3) 4) 5) 6) 7) 8) Signature: _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ Printed Name: ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Month day, 199__ __________, 199__ __________, 199__ __________, 199__ __________, 199__ __________, 199__ __________, 199__ __________, 199__ __________, 199__ Page 2 of 2