Escape Alive Host Application

Organization Name*
School, Club, Company, etc.
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name*

First NameLast Name
Title
Contact Email*
example@example.com
Contact Phone*

Area CodePhone Number
Venue Name (If different than Organization)
Venue Address (If different than Organization)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Room Size (# of square feet of open space)*
How did you hear about our Escape Alive Survival Skills program?*

Company/SponsorEnewsletterFlyerFriend/FamilyPrint MediaRadioSocial MediaVoice2Change PodcastWebsiteOther
Name of Company/Sponsor*
Name of friend/family member*

First NameLast Name
Covid-19 Disclaimer
The staff of Jane Doe More More, East Coast Training Systems and their sponsors cannot guarantee a Covid-19 free environment. Our Escape Alive Survival Skills classes involve the use of shared equipment, close physical contact and we will not require proof of vaccination or the use of masks from staff or participants.

I,   First Name   Last Name ,  on behalf of   Name of Organization and    Name of Venue    acknowledge and understand the contagious nature of COVID-19 and exposure or infection may result in personal injury, illness, permanent disability, and death. I hereby covenant and agree to defend, indemnify and hold harmless Jane Doe No More, East Coast Training Systems and their sponsors against any and all liability, loss, damages, claims, or actions (including costs and attorney's fees) of any nature or kind including those for bodily injury, to the extent permissible by law, arising out of or in connection with hosting an Escape Alive Survival Skills class.

Signature
How would you promote the class?*
Class Selection

Mother/Daughter - Minimum age of 12 (also open to individuals)Adult - Minimum age of 15
Date of Class *

MonthDayYear
Saturday or Sunday Only
Time of Class*

1:00pm-5:00pm (Saturday)9:00am-1:00pm (Sundays Only)1:00pm-5:00pm (Sunday)1:00pm-3:00pm (Saturday)1:00pm-3:00pm (Sunday)
2nd Proposed Class Date *

MonthDayYear
Saturday or Sunday Only
Time of 2nd Proposed Date (may be subject to change)*

1:00pm-5:00pm (Saturday)9:00am-1:00pm (Sundays Only)1:00pm-5:00pm (Sunday)
Feel free to leave any additional information or questions.
Acknowledgement
I, First Name Last Name acknowledge and understand the responsibilities of both parties listed at the top of this application.
Signature
There will be an additional travel expense for all classes if 1 hour or more round trip from Middlebury, CT.

Our Escape Alive Survival Skills program relies on funding from individuals, organizations, businesses and foundations. We are happy to work with you to bring this program to your community.
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