Workshop Rules Consent Form (课堂规则同意书)「課堂規則同意書」

Applicant’s name：

I, __________________, a Term Member of the Association, am applying to join and participate in the following workshops (please tick whichever applicable) and consent to the rules of the workshops herein contained:

o HarmonyQi;

o EnerQi Beginners;

o EnerQi Intermediate;

o EnerQi Advance;

o YoungQi Beginners;

o YoungQi Intermediate; and

o YoungQi Advance.

Article 1 Eligibility

I agree to adhere to all the workshops and class rules herein contained including but not limited to the following, should a violation thereof occur, the Association reserves the right of legal proceedings.

1. Wearing my membership pass and the uniform of the Association before entering the workshop(s)’ classroom(s) and at all times therein;
2. Not lending my membership pass to any other person and keeping my membership pass safely and in my possession at all times as I understand that the same is being referred to by the Association when allowing participants to participate in their workshops;
3. Obtaining the consent of the Association and be registered in the designated list before entering the workshop(s) classroom(s) after the end of each training session;
4. Paying the requisite fee to the Association for the replacement of my membership pass in the event of the same being stolen, lost, destroyed and/or damaged;
5. Reporting the identity if my relatives and/or friends accompanying me to the workshops. I understand that they are not allowed to enter the workshop(s)’ classroom(s).
6. Members without prior approval of the Association, or Members who are not included in the Training Programme, or Members whose eligibility do not meet the qualifying criteria for participation are not permitted to participate, attend and join in the Training Programme and related activities, including but not limited to group practices, revisions, enhancement and fine-tuning courses, seminars, workshops and dialogues, etc.

Article 2 Rights and Obligations

I have read all the relevant membership terms, member’s statement of rights and obligations (complete contents of which can be found in the membership application form, the other forms executed by me prior to my admission to the Association, the Association’s website and Constitution) and I hereby agree, acknowledge and undertake to adhere to all the relevant rules of the Association which are applicable to me from the said sources and from all the resolutions passed by the Association.

Article 3 Agreement on Authorship and Copyright

I agree to adhere to the rules of the Association on the authorship, copyright and intellectual property of the Association. I agree, acknowledge and understand that:

1. Audio recordings, video recordings and photography, of the workshop(s) are strictly prohibited irrespective the location(s) and/or venue(s) of which they are held.  Without prior written consent of the Association, audio recording, video recording, and photography are not permitted. Once violation of these regulations is ascertained, the Association reserves the right to exercise its rights over legal prosecution. In addition to the punitive penalty of NTD10 million, the Association reserves the right to seek compensation and recourse for all damages suffered and incurred.
2. The contents taught by the Association shall be under the protection of intellectual property patent rights, its registered contents include but are not limited to names and particulars of the workshop(s) trainings, contents of trainings and handouts, music for practices, etc.  Without the consent of the Association, Members are prohibited from transferring technique and content to others;
3. I shall not disclose, distribute and/or teach any of the Association’s contents, materials and/or information to any other person without the consent of the Association.  Without the consent of the Association, Members are prohibited from transferring technique content to others;
4. Members are prohibited from teaching, instructing, training, sharing, or conveying any technique content, whether in private or public, without the written permission of the Association. In the event of violation thereof, the Association reserves the right of legal proceedings regardless whether or not damage to reputation, and / or injury, harm, damage, deterioration of state of health, undesirable circumstances, etc.,  are involved.
5. I shall fully indemnify and hold harmless the Association and/or its’ personnel from and against all claims, suits, demands, actions and/or proceedings that may be brought against the Association and/or its’ personnel and/or all losses, damages, expenses that may be incurred or suffered by the Association and/or its’ personnel in the event of any undesirable consequences caused by me to the Association as a result of any breach of my duty of non-disclosure herein contained.

Article 4 Health Conditions, Safety and Life

I fully declare and confirm that I am fully aware and understand the following:

1. That during my participation in any of the workshops, trainings, activities or group practices as may be organized and/or conducted by the Association or otherwise irrespective of the location of which the same is being conducted or held at, in group, individually or otherwise (“My Participation”):i) I must at all times assess and monitor my own physical strengths, fitness, abilities and health conditions and not overexert and/or perform any improper techniques, exercises and/or physically exhausting activities and adhere to the guidance and instructions of the Association; andii) Immediately stop practice and forthwith seek medical attention and assistance in the event I experience and/or suffer any cold sweats, discomfort, pain, sprain, shortness of breath, palpitation, angina, headache, bleeding dizziness, vomiting, injury etc. or encounter any accidents and/or incidents including but not limited to falling or bruising.
2. That the purpose of the qigong practice is to improve my overall health conditions but it shall not in any manner be a substitute to any of the medical treatments and/or medications that I am undergoing or shall undergo, taking or shall take and the proposed regime needs to be combined with my regular treatments (if any);
3. That I shall not stop and/or reduce the dosage of my medical treatments and/or medications I am undergoing or taking (if any), without any professional medical advice;
4. That the Association does not warrant that their qigong methods, techniques, workshops, trainings, group practices, activities and/or information will be suitable to me and/or meet my expectations;
5. That there are risks associated with any form of exercise and/or regimen. As such, I agree and undertake as follows:i) To assume all risks, take full responsibility and accountability for my own safety and/or life for all eventualities which may take place during My Participation; andii) To waive, withdraw, renounce and/or disclaim all claims, requests, demands whatsoever against the Association and/or its’ personnel including but not limited to any on-site attendants, staff, helpers, volunteers whatsoever on all their legal responsibilities in all circumstances irrespective of how from caused and whether or not they are caused by the personnel’s mistakes or negligence in the event I suffer from death, any future or current discomforts, accidents, incidents, injuries, damages, losses whatsoever in future which may arise due to My Participation and/or as a result of me practicing any qigong methods and/or techniques as may be taught and/or promoted by the Association; and
6. That if I faint during My Participation, the Association will call an ambulance and/or perform CPR or AED on-site (whichever is applicable).

Article 5 Special Reminders

I have been clearly informed and advised by the Association as follows:

1. That there are differences in each regimen, school and method of qigong exercise;
2. That in the beginning, I need to learn and practice qigong single-mindedly to obtain the best results; and
3. The trainings provided by the Association do not contradict with other forms of exercises, yoga, massage (tuina), acupuncture, folk therapy, zen meditation etc., and I may engage in all the other activities as usual and eat normally during my period of practice.

Article 6 Outdoor Group Practices/Trainings

1. I voluntarily agree to participate in the outdoor group practices and/or trainings organized and/or conducted by the Association and I understand that they are organized and/or conducted for members’ benefits.
2. The Association has the right to make changes to and/or cancel any trainings and/or practices without the need to inform me or seek my consent.

Article 7 Consent to Authorization

I agree that for the entire duration of the workshop(s), the Association may record videos, audios and take photos of the workshops and/or trainings and I authorize the Association to use such photographs, video and/or audio recordings, my response reports, testimonies etc. for any purpose the Association deems fit including but not limited to purposes of data

collection, publications, online publications etc.

Article 8 Collection of Personal Data

I agree and consent to the collection and use of my personal data by the Association and/or their personnel for purposes the Association deems fit.

Article 9 Turning Off Mobile Phones

I understand that mobile phones’ signals may impede and affect the quality of qi transmission and I agree to turn off my mobile phone(s) immediately upon entering the hall and/or classroom(s).

Article 10 Taking Care of Belongings

I understand that the hall is a public place and I have to take care of and be responsible for my personal belongings and that the Association shall not be in any manner responsible for any losses, damages whatsoever of any items in the hall. I shall indicate my name on my personal belongings and on any workshop(s)’ items handed to me immediately including but not limited to any handouts, complimentary gifts etc.

Article 11 Principles to Follow

1. I agree to abide by the principle of “Honour the teacher and respect his/her teachings”.
2. I agree, undertake and covenant not to make and/or disseminate in any manner any information which may be unfavourable and/or defamatory to the teacher(s) and/or the Association which I may come across during or after the workshop(s)’s period.
3. I understand that if I make, disseminate or distribute or cause to make, disseminate or distribute any information which potentially defames and/or affects the reputation of any of the teachers(s) and/or the Association, the Association and/or the teacher(s) shall be entitled to take the necessary legal actions against me, costs and expenses of which shall be borne solely by me. I further agree to bear all losses and damages which may be suffered by the teacher(s) and/or the Association as a result of the same.

Article 12 Declaration of Health Conditions

1. I hereby confirm that I have filled up all the necessary forms prior to my admission as a member to the Association, including but not limited to the physical health declaration form, major illnesses declaration form and the membership application form.
2. I understand and agree that the terms and conditions of the aforesaid forms shall be binding to the full extent permitted by law and shall also bind my heirs, personal representatives, successors in titles and permitted assigns.

Article 13 Agreed Matters

I have read and agreed to all the terms and conditions of this form and I agree to be bound by the same.

Article 14

If I disagree with any of the terms and conditions herein contained, I shall not proceed to apply to join the workshop(s).

Health Condition Declaration Form (身体健康状况告知同意书)「身體健康狀況告知同意書」

Those with the health condition listed herein shall sign this consent and declaration form if he/she wishes to apply for a term membership in the Association.

I ________________________ am applying to join the Association as a Term Member and I voluntarily agree to participate in all workshops, trainings, group practices and activities which may be organized and/or conducted by the Association.

I have been informed that since I have sought medical advices or was treated in the past for

or is currently being treated or is suffering from any of the illnesses and/or health conditions

listed herein, it is recommended for me to seek medical advices from professional physicians

to assess my physical strengths, fitness and abilities before attending and/or participating in

any of the workshops, trainings, group practices and activities of the Association.

I hereby declare and confirm that I have sought medical advices or was treated in the past for or is currently being treated or is suffering from any of the following illnesses and/or health

conditions (please tick whichever relevant):

• Unexplained chest discomfort (chest tightness, chest pain)不明原因的胸部不适（胸闷、胸痛）;
• Unexplained breathing difficulties不明原因之呼吸困难;
• Unexplained vertigo不明原因之晕眩;
• Dizziness头晕;
• Hypertension (above 140/90Hg)高血压（140/90Hg以上）;
• Asthma气喘;
• Alcohol or drug abuse and/or addiction酒精或药物滥用成瘾;
• Diabetes mellitus糖尿病;
• Hypotension低血糖;
• Hyperlipidemia (total cholesterol greater than 240 mg/DI)高血脂症（总胆固醇大于240mg/DI）;
• Anemia (aplastic anemia, thalassemias)贫血（再生不良性贫血、地中海型贫血）;
• Eesophageal/gastric/duodenal ulcer (malignant tumour) etc.食道、胃、十二指肠溃疡、癌症(恶性肿瘤)等;
• Others, please state其它，请列出:_____________________

Due to my illnesses and/or health conditions, I fully declare and confirm that I am fully aware

and understand all of the following:

1. That the purpose of the qigong practice is to improve my overall health conditions but it shall not in any manner be a substitute to any of the medical treatments and/or medications that I am undergoing or shall undergo, taking or shall take;

2. That the Association does not warrant that their qigong methods, techniques, workshops, trainings, group practices, activities and/or information will be suitable to me and/or meet my expectations;

3. That during my participation in any of the workshops, trainings, group practices and activities which may be organized and/or conducted by the Association or otherwise, irrespective of the location of which the same is being conducted or held at, in group, individually or otherwise (“My Participation”), I must:-i) At all times assess and monitor my own physical strengths, fitness, abilities and health conditions and not overexert and/or perform any improper techniques, exercises and/or physically exhausting activities and adhere to the guidance and instructions of the Association; andii) Immediately stop practice and forthwith seek medical attention and assistance in the event I experience and/or suffer any discomfort, pain, headache, bleeding, dizziness, vomiting, injury etc. or encounter any accidents and/or incidents including but not limited to falling or bruising.

4. That there are risks involved in any form of exercise and/or regimen. As such, I agreeand undertake as follows:i) To assume all risks, take full responsibility and accountability for my own safety and/or life for all eventualities which may take place during my Participation; andii) To waive, withdraw, renounce and/or disclaim all claims, requests, demands whatsoever against the Association and/or its’ personnel including but not limited to any on-site attendants, staff, helpers, volunteers whatsoever on all their legal responsibilities in all circumstances irrespective of how from caused and whether or not they are caused by the personnel’s mistakes or negligence in the event I suffer from death, any future or current discomforts, accidents, incidents, injuries, damages, losses whatsoever in future which may arise due to My Participation and/or as a result of me practicing any qigong methods and/or techniques as may be taught and/or promoted by the Association; and

5. That if I faint during My Participation, the Association will call an ambulance and/or perform CPR or AED on-site (whichever is applicable);

I have read all the above terms and conditions in detail, and I understand and agree that the terms and conditions of this consent and declaration form shall bind my heirs, personal representatives, successors in titles and permitted assigns.

This declaration of consent is valid and binding to the full extent permitted by the law of the country the Association registered.

I hereby confirm that I have read, understand and agree to all the above terms.

課堂規則同意書

會員姓名：　　　　　　　　　　

第 一 條 資格證明

我同意遵守所有課堂規則。

會員必須經過白雁自主健康管理學(以下稱 “本會”)同意並在指定名單中才可再進入訓練。

未經本會同意的會員、未在訓練名單的會員 或 經審查資格不符合的會員，均不得參與該訓練及相關活動，包括但不限於團練、複習、查功、座談等，亦不得跟練該訓練課程或功法動作，一經查獲有違反情事，協會將保留法律追訴權。

第 二 條 權利義務

我已經閱讀所有相關之服務條款、會員權利義務聲明。

會員有遵守本會章程、決議及繳納會費之義務。本會每年需續約申請，未申請或未參與本會活動超過一年，視為自動退會。會員福利每年更正，細節需遵照官網說明指示。

第 三 條 著作權版權協定

我同意遵守協會和白雁自主健康管理學的著作權、版權、智慧財產權規定。

參與本會舉辦的訓練、活動、培訓、座談、演講會、團練、複習、查功，進行方式包括但不限於數位線上或實體地點，未經本會事先書面同意，不得錄音、錄影、照相等。一經查實違反規定，將行使法律追訴權，除懲罰性違約金新台幣一千萬元外，得請求賠償所有實際之損害。

本會所授內容均受智慧財產專利保護，其註冊內容包括講義內容、練功音樂、訓練內容、訓練名稱等，未經本會同意，請勿將所學之方法內容轉授他人。

未經本會同意許可認證，不得私自或公開教授、傳授、指導訓練內容與功法動作。如未經同意而教授指導所造成誤導、名譽傷害或身體健康惡化等不良後果，協會將保留法律追訴權。

第 四 條 生病就醫

我清楚明白，我有責任在白雁自主健康管理學任何訓練或者團體活動中，自行判斷個人體能及身體健康狀況，避免過度或勉強練習，並斟酌個人健康狀況，遵守本會之指導，自行決定是否參與活動。

我清楚明白由於每個人的健康狀況不同，而對運動、肢體活動所作出的反應可能有極大差別，會注意自身安全並同意自主管理。我知道如果練習中發生不明疼痛、扭傷、腹痛、頭痛、頭暈、出冷汗、氣短、心悸、心絞痛等問題，會自主立即停止練習並盡速自行就醫。

我已經清楚被告知，任何養生運動均為保健和健康促進的原則，並無醫療承諾，仍需配合正規治療，我也清楚被告知不能自我判斷停藥、減藥或者停止任何正規治療。

第 五 條 特別提醒

我已被清楚告知，各種養生方法以及各家氣功功法氣路不同，是否會相互抵觸無從而知。

協會建議學員在初學時，需專一學習，專一練習，以利最佳化的學習效果。本訓練與其他運動、瑜珈、推拿按摩、針灸、民俗療法、禪修等不抵觸，在練習期間所有活動、飲食均可照常。

第 六 條 團練

我自願參加協會指定的團練(含戶外與線上)。

所有團練或輔導均為會員福利，協會有權利修正、調整、終止任何項目，並不需要事先通知或徵得會員同意。

第 七 條 同意授權

我同意受訓期間，協會或者機構可以錄影，錄音，照相記錄上課之所有情況。

會員或者學員授權協會或者機構使用本人課堂之照片，影片於書籍著作，網路，手冊等。本人同意將受訓期間之錄影，錄音，照相以及心得報告，見證等，經修正後授權與協會或者機構作為資料收集，出版，網路出版等使用。如果不同意此項，請與協會連絡辦理退費手續，因協會紀錄無法保證完全避開您，恕協會無法繼續為您服務。

第 八 條 個人資料蒐集

本人同意本協會授權之單位得蒐集、處理及利用本人所提供之個人資料。

第 九 條 請關手機

我清楚明白進入實體課室上課及相關複習、查功、團練、採氣等活動會場後，關機手機的必要性。

手機訊號有礙氣場淨化，會造成信息紊亂，影響上課品質。

第 十 條 物品保管

參加實體課室上課及相關複習、查功、團練、採氣等活動會場乃公共場所，我會自行保管私人物品。

協會不負任何個人物品遺失責任。請立即在講義、提帶、贈品上註明您的姓名以免遺失。

第十一條 遵守原則

我同意遵守「尊師重道」原則。

在學習期間或之後，不得公開或者私下散佈誹謗協會或者不利於老師以及協會之言論。如有任何明確或者暗示之舉動，造成對白雁彥寬老師個人以及白雁自主健康管理學負面影響的「與事實不符」的宣稱，造成名譽損害，除將喪失所有會員或者學員權益，並同意繳回所有會服之外，並且願負所有之後

續法律責任。

第十二條 健康聲明

我已經如實填寫身體健康狀況告知同意書及/或重大疾病者聲明同意書。

1. 任何癌症，無論是否有做過正統醫療治療、或正在做癌症放療、化療或您有其他特別病歷史等，都應於學習前向本機構主動說明。
2. 入會者如曾經有不明原因的胸部不適（胸痛、胸悶），不明原因的呼吸困難，家族心臟病、糖尿病史等皆屬心肌梗塞高危險群，建議入會前請教醫師並慎重考慮是否適合參加任何運動。
3. 如果您有以下問題，請慎重考慮自身安全勿勉強參與氣功運動，或請醫師評估風險並通知本協會做退費等處理：嚴重之高血壓、嚴重心臟衰竭、腦中風（腦出血、腦梗塞）、腦瘤、腦動脈血管瘤、腦動脈硬化症、癲癇、巴金森氏症、主動脈血管瘤、狹心症、心肌肥厚、風濕性心臟病、先天性心臟病、有裝置心臟起搏器、心導管手術、肺氣腫、支氣管擴張症、肺結核、肺栓塞、裝置人工關節、動大手術不滿一個月、視網膜剝離、肝硬化、尿毒、血友病、白血病、孕婦、憂鬱症、有精神病史、愛滋病或愛滋病帶原、因為參加其他學習班或者學習方法走偏者。

第十三條 免責聲明

本會不提供任何明示或默示的擔保，包含但不限於醫療承諾及身體改善等保證。本會不保證以下事項：

1. 本會不保證提供之會員服務將符合您的需求。
2. 本會不保證您經由本會取得之任何服務、活動、資訊將符合您的期望。
3. 申請人須自行判斷個人體能及身體健康狀況，避免過度或勉強練習，並斟酌個人健康狀況，遵守本會之指導，不做不當之運動或參與其體力無法負荷之活動。
4. 本會不保證此方法對所有身體狀況及體質適合，請事先並及時請教專業醫師，以確保您的身體適合運動和練習。
5. 由於每個人的健康情況不同，而對運動、肢體活動所作出的反應可能有極大差異，因此本會不可能絕對清楚確定此訓練或方法是否在某種情況及環境下適合某人練習。無論是單獨自我練習或於受訓中、戶外團體練習、線上團練，本會一概不會承擔任何有關方法練習安全性及合適性問題的任何責任。
6. 如練習過程中發生疼痛、扭傷、腹痛、頭痛、出血、頭暈、嘔吐等症狀，或於室內團練中或戶外團練過程中發生跌倒、撞傷等意外應立即停止練習並盡快就醫。
7. 在考慮加入本會後，本人對於因參與本會任何訓練或團練或活動而導致本人現在或未來可能的不適、死亡、個人傷害、財產損失，願意放棄、免除、撤銷任何之索賠。本聲明同意書將免除本會之所有人員包含現場服務人員之法律責任，無論現場服務人員是否本會之員工或會員，且即使該法律責任是因前述人員的失誤或疏失所造成的。
8. 申請人已經詳細閱讀以上所有描述，同時瞭解任何團練、訓練和活動可能帶來實質的危險與風險。申請人瞭解並同意此聲明，也同時約束申請人之繼承人、代理人、近親、配偶、或受讓人。

身體健康狀況告知同意書

申請人　　　　　　　　　　申請加入 貴會，並自願同意參與 貴會舉辦之所有訓練、複習、查功、團練、採氣以及活動，包括但不限於實體、戶外或網路方式。

白雁自主健康管理學所傳授的養生法，是非常安全的養生運動方式，符合大部分人的保健需求，並對健康促進有良好效果。然而，如會員自身有疾病，或潛在而未知的疾病，無論任何運動或保健法，任何形式，都有一定的潛在風險。

申請人充分知悉且了解，如申請人於過去曾經因以下疾病而就醫或治療，將有可能無法接受 貴會之訓練課程、團練以及活動，因此申請人同意 貴會得蒐集申請人之健康狀況，且申請人有義務誠實告知，如申請人未誠實告知，申請人願自負責任，並同意不得向 貴會為任何民、刑事相關法律之主張或請求：

• 不明原因的胸部不適（胸悶、胸痛）、不明原因之呼吸困難、不明原因之暈眩、頭暈
• 心肌梗塞、心導管手術、心臟起搏器、狹心症、心肌肥厚、心內膜炎、風濕性心臟病、先天性心臟病、主動脈血管瘤
• 腦中風（腦出血、腦梗塞）、腦瘤、腦動脈血管瘤、腦動脈硬化症、癲癇
• 巴金森氏症、精神疾病
• 視網膜剝離
• 肺氣腫、支氣管擴張症、肺結核、肺栓塞
• 愛滋病或愛滋病帶原
• 手術不滿一個月、人工關節
• 胰臟炎
• 因學其他學習班或者學習方法走偏者
• 重大手術史
• 懷孕
• 惡性腫瘤中末期
• 器官移植手術