Rocky Booth Form

First Name *

Last Name *

Phone *

Email *

Practice Name *

Your Position *

How Much In Collections Have You Averaged Per Month In The Past Six Months? *

How much do you currently spend per month on digital marketing? This includes agency fees and ad spend. *

Release of Liability to Participate

By either signing below or completing the online waiver; I hereby acknowledge that I have read or otherwise received all rules, warnings, and restrictions related to LVRG Media Punching Contest.

I hereby acknowledge that I have read or otherwise received all rules, warnings, and restrictions related to LVRG Media Punching Contest.

I hereby certify that I understand the above risks associated with this LVRG Media Punching Contest and agree that LVRG Media shall not be responsible for any injuries or losses sustained by me during activity in the LVRG Media Punching Contest.

Additionally, I agree to be held solely responsible if my negligence, willful misconduct, or disregard for the rules of LVRG Media Punching Contest leads to damage to others or to LVRG Media Inc and PHReedLLC (DBA Chirofest) n Inc property provided for the activity.

Any legal manners arising from this release of liability shall take place in the state of Illinois as agreed.

I am in complete understanding of the risks associated with this event or activity, including, but not limited to, the following:

→ Broken bones

→ Sprained ankles

→ Back injury

→ Brain injury

→ Skull fracture‌

→ Concussion

→ Torn ligaments

→ Cuts and bruises

→ Finger injuries

→ Any other injuries not listed

I agree to hold harmless and indemnify and defend LVRG Media and PHReedLLC (DBA Chirofest) against all claims, causes of action, damages, judgments, costs, property damage, or expenses, including attorneys’ fees and other litigation which in any way arise from my own or, if applicable, my family’s use of or presence upon the facilities of the event during the LVRG Media Punching Contest while participating in said activity.

I agree and acknowledge that I am under no pressure or duress to sign this liability waiver and that I have been given a reasonable opportunity to review this general release of liability form. I acknowledge that any deposit monies will be refunded and that I may not be able to participate in LVRG Media Punching Contest if I choose not to sign this waiver. I consent that I understand that participation in this activity is voluntary.

I accept this release of liability as the complete terms between myself and LVRG Media and PHReedLLC (DBA Chirofest) while participating in LVRG Media Punching Contest.

BY SIGNING BELOW, BOTH PARTIES AGREE TO THE TERMS CONTAINED WITHIN THIS AGREEMENT AND ACKNOWLEDGE UNDERSTANDING OF THE TERMS AND CONDITIONS CONTAINED HEREIN, INCLUDING THE VOLUNTARY SURRENDER OF CERTAIN LEGAL RIGHTS.

Signature

Clear

Rocky Release Form Signature Date

I agree to terms & conditions provided by the LVRG Media. By providing my phone number, I agree to receive text messages from LVRG Media. Message frequency varies, data rates may apply, and reply STOP to opt-out.