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Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Checkbox *

Male

Female

Emergency Contact *

First Name

Last Name

Emergency Contact Phone

(###)

###

####

I am attending (Please choose one) *

Leg A

Leg B

Bonus Leg C

Christmas Leg

By checking yes below, this constitutes my signature and agreement with the above statement.

YES––applicant's signature

YES––Parent / Guardians signature (if under 18)

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. *

yes

no

Checking the box below constitutes my signature and agreement to the statement above *

This check constitutes my signature either as an individual 18 years of age or older or as the guardian of this applicant.

Today's date *

MM

DD

YYYY

Liability Release Form *

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 in directly 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.

YES––Checking this box constitutes the applicant's signature

Today's Date *

MM

DD

YYYY

Any participant who is less than 18 years of age must also have a parent or legal guardian complete the following:

YES––Checking this box constitutes the signature of the legal guardian of this applicant.

Today's Date *

MM

DD

YYYY