Liability Form LIABILITY WAIVER AND RELEASE Participant's Name(Required) First Last Please Select Which You Are: Adult (18+) with Minors Adult (18+) without Minors Minor How many Minors will you be bringing?Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Participant's Phone(Required)Participant's Email(Required) Name of Emergency Contact First Last Relationship of Emergency Contact Emergency Contact Phone NumberBY SIGNING THIS DOCUMENT YOU WILL WAIVE LEGAL RIGHTS INCLUDING THE RIGHT TO SUE SIXTY-ONE ACRES, INC. I, the undersigned, wish to participate in the hikes and outdoor activities (the “Retreat”), being organized by Sixty-One Acres, Inc., a non-profit corporation organized under the laws of the State of Florida (“Hosting Company”). I wish to participate in the Retreat, and hereby assume all risks of engaging in the Retreat. I understand there is an element of risk inherent in any form of outdoor activity, and I realize there is a chance of an accident occurring, which may result in bodily injury, death, or property damage. By voluntarily participating in the activities being offered, I accept and assume all risk while I am participating in activities conducted. I also hereby hold harmless and release Hosting Company, its members, managers, employees and agents (collectively, “Indemnitees”) and indemnify each of them from and against any and all loss, claim, cause of action, lawsuit, damage, liability, cost or expense whatsoever which any of them may incur arising out of or in connection with my participation in the Retreat. I hereby certify that I am at least 18 years of age. I agree that neither I nor any member of my family will sue any Indemnitee because of my participation in the Retreat at any time, and I understand that this Release shall be binding upon my estate, my heirs, next of kin, executors, administrators, representatives, successors and assigns. I specifically waive any claim or right to assert any cause of action or alleged case of action or claim or demand. I expressly agree that this waiver, release, and assumption of risk is intended to be as broad and inclusive as permitted by applicable law. If any portion of this agreement is held invalid, it is agreed that the balance shall continue in full legal force and effect. This waiver, release and assumption of risk shall be governed by and construed in accordance with the laws of Florida. I further agree that any action, suit or proceeding arising out of or relating to my participation in activities offered by must be brought in a State court in Polk County, Florida within one (1) year of the event(s) giving rise to the action, suit or proceeding. In such an action, the prevailing party is entitled to recover reasonable legal fees and expenses. I state that I am over the age of 18 and have read this Release and understand its contents and sign this Release willingly as my own free act.SignatureName of Participant(Required) First Last Signature of Participant or Parent/Guardian(Required)Additional Parental Consent and ReleaseONLY COMPLETE THIS SECTION IF ONE OF THE PARTICIPANTS IS UNDER THE AGE OF 18.Name of Parent/Guardian First Last I, [name of parent or guardian of minor participant] as the parent or guardian of a person under 18 years of age, in consideration of allowing [name of participant minor's name] allow them to participate in the activities described in the foregoing release do hereby release all the claims of the minor as indicated above. I acknowledge as this is a non-profit organization this activity is non-commercial. The undersigned parent or guardian, executes this release on the minor's behalf and additionally agree on my individual behalf to indemnify and hold harmless the Indemnities from any loss, liability, damage or cost (including but not limited to reasonable legal fees and expenses) they may incur due to the minor's participation in such activities.Name of Minor First Last Name of Minor #2 First Last Name of Minor #3 First Last Name of Minor #4 First Last Name of Minor #5 First Last Name of Minor #6 First Last Signature of Parent/GuardianCommentsThis field is for validation purposes and should be left unchanged.