Name___________________________ Lisle Program____________________

E-mail __________________________ Telephone ______________________

Fax ____________________________ Work Telephone__________________

Permanent

Address ______________________________________________

Street

______________________________________________

City

______________________________________________

State Zip Country

Social Security # _________________ Passport # ____________________

To Lisle Fellowship Inc:

I agree that Lisle Fellowship Inc. is not liable for any injury, damage, loss, accidents, delay or irregularity which may be occasioned by reason of accident in any vehicle; through acts of any company or person engaged in conveying the person; incidents of robbery, theft; or injury, damage, loss or accidents as a result of political instability which may happen in carrying out the arrangements for the program. Persons joining Lisle Fellowship Inc. programs assume personal responsibility for any personal accidents and necessary medical services resulting therefrom, including emergency transportation arrangements.

Date ____________________ Signature_______________________

Participant

Date ____________________ Signature _______________________