Culture In Motion™ Liability Form

1

Group InformationTell us the name and email of your group

Organization / Group Name

Organization / Group Email

2

Group Contact Information Tell us who you are and how we can contact you

First Name

Last Name

Please enter your phone

Email Address

3

Group Contact Information* This field is required.Please provide the primary contact information for the person responsible for this registration

4

Organization / Group Roster* This field is required.Please list the first name, last name and date of birth for all participants attending with your organization or group

5

Liability & Media Release Acknowledgment* This field is required.

6

Signature* This field is required.Electronic Signature Acknowledgment: By signing below, I acknowledge that my electronic signature is legally binding and confirms my agreement to the Liability Release and Media Release.