Applicant Name *

First Name

Last Name

Phone # *

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Date of Birth *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name | Emergency Conact #1 *

First Name

Last Name

Phone | Emergency Contact #1 *

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Name | Emergency Contact #2 *

First Name

Last Name

Phone | Emergency Contact #2 *

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AGREEMENT ASSUMING RISK OR INJURY OR DAMAGE/WAIVER AND RELEASE OF CLAIMS: *

I fully understand that my participation in a ride-along event with KAOTIK MEDIA exposes me to the risk of personal injury, property damage, or death. I hereby acknowledge that I am voluntarily participating in the ride-along, and expressly agree to assume any such risks. In consideration for being permitted to participate in the ride-along, I hereby release and forever discharge the Owner(s) of KAOTIK MEDIA, KAOTIK MEDIA, its photographers, employees, supervisors, agents, and volunteers for any injury, death, or damage to/loss of personal property arising out of or in connection with my participation: including active or passive negligence of the Owner(s) of KAOTIK MEDIA, KAOTIK MEDIA, its photographers, employees, supervisors, agents, volunteers, or any other participants in the event. In further consideration for being allowed to participate in the ride-along, I hereby agree for myself, my heirs, administrators, executors, and assigns, that I shall indemnify and hold harmless the Owner(s) of KAOTIK MEDIA, KAOTIK MEDIA, its photographers, employees, supervisors, agents, and volunteers from any and all claims, demands, actions, or suits arising out of or in connection with my participation in the event brought by any third party. I HAVE CAREFULLY READ THIS WAIVER AND FULLY UNDERSTAND ITS CONTENTS. DURING MY PARTICIPATION IN THE RIDE-ALONG EVENT, I HEREBY AGREE TO FOLLOW ALL OF THE LAWFUL COMMANDS OF THE KAOTIK MEDIA PHOTOGRAPHER(S) AND FURTHER AGREE THAT I WILL NOT BRING WITH ME ANY FIREARMS, WEAPONS, OR ILLEGAL ITEMS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILITY AND SIGN IT OF MY OWN FREE WILL.

Acknowledged & Agreed

Electronic Signature *

First Name

Last Name

Parent/Guardian Electronic Signature (If Under 18)

First Name

Last Name

Today's Date *

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