August 5, 2016

Shot Gun 8:30PM

Carthage, TN

(Smith County)

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STOMP MS AMERICA

WAIVER RELEASE AND CONSENT

In consideration of Stomp MS permitting (me)(my child __________________________________________, who is under 18) to participate in the above-named event, I hereby, and for (me)(my child) heirs, executors, administrators, assigns and all legal guardians, WAIVE AND RELEASE ANY AND ALL RIGHTS AND CLAIMS OF ANY NATURE, FOUNDED IN WHOLE OR IN PART UPON ANY TYPE OF NEGLIGENCE, that (I) (my child) may have against Stomp MS, its directors, officers, employees, agents, chapters, assignees, licensees, volunteers and cooperating entities, their representatives, heirs, executors, administrators, successors and assigns (the “Release Parties”) arising out of or resulting from any and all injuries or damages of any nature, including death, which (I) (my child) may suffer while taking part in the event or any activities connected with the event. I UNDERSTAND THAT THIS MEANS I AGREE NOT TO SUE any or all of the Released Parties in connection with the event.

                       Consent also is hereby given to use (my) (my child’s) name, picture, portrait, likeness in any media for educational promotional and advertising purposes in furtherance of the corporate purposes and objectives of Stomp MS.

                      By signing this document, I certify that I have read this document and fully understand it, and that I am not relying on any statements or representations of any Released Party. This document shall be binding upon me, (my) (my child’s) heirs, executors, administrators, assigns and all legal guardians (of my child)

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