Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

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121 Liability release *

In consideration of attending any 121 inc. tour and/or event, I hereby affirm that my family and I agree to hold 121 inc. harmless from any and all claims, liabilities, losses, demands, causes of action, suits and expenses (including attorney fees), which may directly or indirectly be connected to 121 inc. and/or my presence on 121 inc. tours and/or events, specifically related to but not limited to operation of 121 inc. production equipment and 121 inc. transportation. I further agree to indemnify any party indicated above should such party suffer any claims, liabilities, losses, demands, causes of action, suits and expenses (including attorney fees), caused directly or indirectly by my negligent or intentional acts, or failure to act, or if such acts or failures to act are directly or indirectly caused by any person in my family or associates while participating in a 121 inc. tour and/or event. My signature upon this form also indicates agreement and acceptance on behalf of all minor children (under 18 years of age) under my care in attendance. 121 inc. only recognizes those who have registered with 121 inc. and have a signed Liability Release Form on file as participants of a 121 inc. tour and/or event. I have read this form and fully understand that by signing this form, I am giving up legal rights and/or remedies that may otherwise be available to me. By checking yes below, you acknowledge that you are the guardian of this student or you are over the age of 18––and that this constitutes your signature and agreement to this form.

Yes, I Agree

In the event of an emergency where medical treatment is required, I give my permission to the 121 inc. leadership to obtain the services of a licensed physician. Please attempt to notify me immediately concerning any such emergency. By checking yes or no you acknowledge you are the guardian of this student or are over the age of 18. *

Yes

No

Emergency Contact Phone Number *

(###)

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To Bring Not To Bring *

I have read the To Bring Not To Bring information on the one21.life 127 Winter Retreat page.

Yes