Welcome to the Academy

Name 1

First Name

Last Name

Phone 1

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Name 2

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Phone 2

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Date

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Payment Option

Pay in full ($3000)

Split payment ($1500+$1500)

Member's Name

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Address

Address 1

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City

State/Province

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Authorize restaurant charges to be placed on credit card listed above

I authorize the Wine Academy and the financial institution set out above to debit the bank account or credit card I have provided above

Yes

No

Signature

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Last Name

Date

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Are you a wine collector?

Yes

No

Are you interested in wine education?

Yes

No

Will you host company/corporate events?

Yes

No

Would you like to book a private, complimentary session with our in-house Sommelier

Yes

No

Registration Form and Release Waiver

In consideration of myself, a Wine Academy member, being allowed to participate in the “Wine Academy Restaurant Partnership Program” wherein as a member of Wine Academy, I am allowed to bring one (1) bottle of wine with absolutely no corkage fee to participating Restaurant Partners, I agree to the following: I agree to allow Wine Academy and its employees directly related to the administration of this program to share all pertinent and relevant information with Wine Academy Restaurant Partners that is necessary to book and manage a reservation on behalf of myself, if requested. This may include contact information such as name, email, phone number, allergies and dietary restrictions. I agree to allow Wine Academy and its employees directly related to the administration of this program to share my credit card information with the Wine Academy Restaurant Partners insofar as upon request by Wine Academy Restaurant Partner in order to ensure the reservation is confirmed and booked if and only if the Wine Academy Restaurant Partner requests this information. I understand that presentation of my “Gold Membership Card” to Wine Academy Restaurant Partners is necessary to be granted no corkage on one (1) bottle of wine at participating Restaurant Partner. I understand that the Wine Academy Restaurant Partner may additionally request identification to verify and will provide this upon request. I understand and agree that my “Gold Membership Card” remains the property of Wine Academy and is not transferable and may not be shared with anyone else, including other Wine Academy members. Upon termination of membership Wine Academy requires this card to be returned to its possession. In the event the card is lost at any point during membership, or at termination, I understand and agree I will be charged $10.00 for either a replacement or in lieu of card. I understand and agree that it is my sole responsibility to cancel any reservations with Wine Academy Restaurant Partner prior to reservation in the event I am unable to attend to my reservation. Wine Academy is not responsible to ensure cancellations are received by Wine Academy Restaurant Partners in a timely manner and is not responsible for any cancellation fees that are incurred by myself, the Wine Academy member. I understand that Wine Academy is not responsible for the transport of my wine beyond my personal cellar at Wine Academy to the Concierge Desk at Wine Academy. Wine Academy may from time to time elect to transport my wine on my behalf to Restaurant Partner upon request. I understand and agree that Wine Academy is not responsible for breakage or loss of bottle of wine during this transport. I agree to indemnify and hold harmless Wine Academy, its employees, administrators, directors, agents, officers, volunteers, and owners of any financial obligations due to this breakage, should it occur. I understand and agree that Wine Academy will share with Restaurant Partner all dietary restrictions and allergies as instructed by myself. In the event of errors or omissions in transfer of information it is the sole responsibility of myself to inform Restaurant Partner of this. I hereby release, discharge and agree to hold harmless Wine Academy, its employees, administrators, directors, agents, officers, volunteers, and owners from all liability, claims, demand losses or damage losses resulting from dietary restrictions and allergy concerns not being adhered to by Restaurant Partner participant. I have read this agreement, fully understand its terms, and understand thatI have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability pertaining to the contents of this document to the greatest extent allowed by the law and agree that if any portion of this agreement is held to be invalid, that the balance, notwithstanding, shall continue in full force and effect.

Yes

No

Signature *

Please note: a one time processing fee of $150 will be applied to your first invoice

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Last Name