Belize Registration PLEIN AIR AT Caye Caulker, BelizeJanuary 22-30, 2025 Name(required, must match Passport) Address(required) City(required) State(required) Zip Code(required) Phone(required) Email(required) Painter Option(required) I'm a Painter I'm a Non-Painter Accommodations I prefer a single occupancy room. I wish to share a room with another painter. Specify the Full Name of the other painter, if known in the box below. I prefer a painter / non-painter shared room. Specify the Full Name of the companion, if known in the box below. Name of Painter or Companion for room share: First choice of room view: Sunset View Pool View Ocean View Island View (2 Full Beds Only) Second choice of room view: Sunset View Pool View Ocean View Island View (2 Full Beds Only) Workshop Balance Payment Options I prefer to mail a check. Invoice will be emailed to you. I prefer to pay with credit card. Please send me an invoice through the website (payable directly through the website or call the gallery to process credit card payment). **Balances paid via credit card will incur an additional 4% fee** Medical, Dietary or other restrictions: Emergency Contact Name(required) Emergency Contact Phone(required) Belize Watercolor Plein Air Workshop – Janurary 22 – 30, 2025 Wiegardt Studio Gallery (WSG) employees, Eric and Ann Wiegardt, successors, or assigns are not liable for any negligent or willful act or failure to act, of any person, third party or entity which is to, or provides goods or services including but not limited to: transportation companies, equipment suppliers, food service providers of any kind, etc. I acknowledge that I am voluntarily participating in this trip with the knowledge of the inherent risks and dangers involved including but not limited to: negligence on the part of WSG, its employees, Eric and Ann Wiegardt, physical exertion, forces of nature, transportation failures, consumption of alcohol, risks with food or impure water, civil unrest, terrorism, criminal activity, wild or other animals, failure of equipment, accident or illness without means of evacuation or availability of medical supplies or services or adequacy of medical attention once provided, and lost/stolen/or misplaced luggage or property. I hereby agree to be responsible for my own welfare and accept any and all risks of delay, un- anticipated events, inconvenience, illness, injury, emotional trauma or death. I hereby release and discharge forever WSG and employees, Eric and Ann Wiegardt from and against any and all liability arising from my participation in this trip. I agree that this release is legally binding upon me, all members of my family and all minors travelling with me, my family and their heirs, successors, assigns, and legal representatives, it being my intention to release WSG and employees, Eric and Ann Wiegardt, successors, affiliates, and assigns from any and all liability to the maximum extent by laws of both in the United States or outside of the United States. I acknowledge that to participate, I will require a legal passport, and that WSG reserves the right to remove me or any participant it judges incapable of meeting the rigors of activities or who detracts from the enjoyment of the trip by others. I will follow all safety rules presented to me either written or oral by Wiegardt Studio Gallery (WSG). Failure to fill out the Registration Form with signature and the Responsibility Clause with signature(s) will be considered an invalid registration and will remove you from the Belize Plein Air Workshop list. All participants (Painters and Non-Painters) are required to complete both the Registration Form and the Responsibility Clause with signature. Painter Full Name(required) Companion Full Name By Clicking “Register” below we accept that you have read the brochure and understand and agree to the terms and conditions set forth Register Δ
