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WAIVER & RELEASE OF LIABILITY

In consideration of the risk of injury or property damage that exists while participating in Fourth Moon Camp activities, festival, and all other occurrences taking place at the listed address (hereinafter the “Activity); and

In consideration of my desire to participate in said Activity and being given the right to participate in the same;

I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, “Releasor,” “I” or “me”, which terms shall also include Releasor’s parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims, or causes of action of any kind arising out of my participation in the Activity; and


I hereby release and forever discharge:

Vedant Wade Desai,

Fourth Moon Camp

Desai Living Trust

Ghan Matilal Desai

Gita Ghanshyam Desai


Located at:

Roy Gap Road

Seneca Rocks, WV 26884

Their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors, land/property owners and assigns (collectively “Releases”), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.

ASSUMPTION OF RISK Participant acknowledges that participation in activities at Fourth Moon Camp involves inherent risks including, but not limited to: uneven terrain, wildlife encounters, weather exposure, remote location with limited emergency response, physical exertion, climbing, slacklining, and other outdoor activities. Participant voluntarily assumes all risks, known and unknown.

I am voluntarily participating in an Activity and I am participating in the Activity entirely at my own risk. I am aware of the risks associated with participating in this Activity, which may include but are not limited to: physical or psychological injury, pain, suffering, illness, disability, paralysis, economic or emotional loss, and death. I understand that these injuries or outcomes may arise from my own or others’ negligence, conditions related to travel, or from conditions at the activity location(s). Nonetheless, I assume all related risks, both known and unknown to me, of my participation in this Activity, including all activities occurring on the property located above, whether related to the Activity or incidental thereto.

I further agree to indemnify, defend and hold harmless the Releasees against any and all claims, suits, or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs.

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize below:

To provide all emergency medical care deemed necessary, including but not limited to first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I further acknowledge that this Activity may involve a test of a person’s physical and mental limits and may carry with it the potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able and properly trained, and I agree to abide by the decision of official’s or agents, regarding my approval to participate in the Activity.

I hereby acknowledge that I have carefully read this Waiver and Release of Liability and fully understand that it is a release of liability. I expressly agree to release and discharge Fourth Moon Camp, Vedant Desai, The Desai Living Trust, Ghan Desai, Gita Desai and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors, and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waiver any right that I otherwise have to bring legal action against Releases for personal injury or property damage.

To the extent that statute or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of Releases and/or associated personnel.

I agree that this Release shall be governed for all purposes by West Virginia law, without regard to any conflict of law principles. This release supersedes any and all previous oral or written promises or other agreements.

In the event that any damage to equipment or facilities occurs as a result of my or my family’s or my agent’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness.

I grant permission to all of the foregoing to use my photographs, motion pictures, recordings or any other record of this event for any legitimate purposes. I understand that this event does not provide for refunds in the event of a cancellation, and by signing this Release, I consent that I am not entitled to a refund if the event is canceled before or during the event.

This waiver and release of liability shall remain in effect for the duration of my participation in the Activity, during this initial and all subsequent events and outcomes of participation.

I waive my right to a jury trial.

If any provision is held invalid, the remainder shall continue in full force and effect.


I certify that I am at least eighteen (18) years of age, medically and mentally sound and physically fit to participate in the event described, above, and am competent to enter into this waiver and release agreement.

If the participant is under eighteen (18) years of age, this document must be signed on behalf of the participant by his or her parents or guardian.

I HAVE READ AND UNDERSTAND THIS PARTICIPATION RELEASE; I UNDERSTAND AND AGREE THAT IT SHALL LEGALLY BIND ME AND MY ESTATE, AND I SIGN IT FREELY, WILLINGLY, AND VOLUNTARILY.

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Parent or Guardian's Email Address
Email*
Confirm Email*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information

I further acknowledge that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize

First Name:
Last Name:
Phone:
Relationship:

To provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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