Release Form

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* 1. Participant name:

First name

Last name

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* 2. Phone number:

Country Code

Phone number

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* 3. Email address:

Email address

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* 4. Emergency contact name:

First name

Last name

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* 5. Emergency contact phone:

Country Code

Phone number

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* 6. Emergency contact email:

Email address

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* 7. Acknowledgements:

INSERT YOUR LIABILITY RELEASE TERMS HERE

I confirm that I am of legal age to give my consent.

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* 8. I consent to participate in [activity] given the acknowledgements above:

I consent

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* 9. Signature:

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* 10. I acknowledge that by entering my name above I am providing a digital signature.

Yes

No

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* 11. Date:

Date

Date