RELEASE FORM

____________________________________________________________      _________________________________

                             EVENT                                                                                       DATE

     The undersigned herein referenced, make application to enter this event above indicated.

     In consideration of the acceptance of my application  to enter this event, I herby waive, release and discharge any and all claims for damages, death, personal injury or property damage, which I may have, or which may subsequently occur to me as a result of my participation in this event. This release is intended to discharge MOOSE INTERNATIONAL, INCORPORATED, any State or Provincial Moose Association and/or any sponsoring Lodge(s), their respective agent(s) and employee(s) from and against and all liability arising out of, or connected in any way with my participation in this event, even though liability may arise out of negligence or carelessness on the part of the person(s) or entity(s) mentioned above.       

     The terms hereof shall serve as a release/and assumption of risk for heirs, executors, successors, administrators and assigns in exchange for my participation in this event.

     I, the undersigned, acknowledge that I am (21) years of age or older and under no physical disability that would prohibit my involvement in this event

     I, the undersigned, attest and affirm that I have read the rules of this event and agree to abide by said rules. I also affirm that the statements from set forth above are true and correct.

     I have read and agree to the condition stated above.

PARTICIPANTS’ SIGNATURE

_______________________________________      ________________________________________

         (Signature)                                                                  (Printed name)

__________________________________________________________________________________

        (Address)

__________________________________________________________________________________

       (City State Zip)                                                                                                         (Phone #)

__________________________________________________________________________________

       (Emergency contact person and phone number)

Lodge / Chapter name and # ____________________________________________________

Date ________________________________________________________________________

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