I, (name)_____________________________________________________ (“Releasor”) residing at (address)____________________________________________________________________________________________________

HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES being conducted by IALI / Dinesh Gulati / Anu Kumar / www.Uplift-You.org and other designated individuals or entities or event holders or sponsors or organizers or heirs or agents or successors (collectively referred to as “Releasee”), at _92 E Old Country Rd, Hicksville, NY 11801 and/or any other designated future or alternate locations, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of Releasee, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability with or without fault.

I CERTIFY that I am physically fit, have sufficiently prepared or trained for participation in this activity, and have not been advised to not participate by a qualified medical professional. I CERTIFY that there are no health-related reasons or problems which preclude my participation in this activity.

I acknowledge that this Accident Waiver and Release of Liability Form will be used by the Releasee of the activity in which I may participate, and that it will govern my actions and responsibilities at said activity.

In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(1) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, any damages or actions of any kind which may hereafter occur to me including my traveling to and from this activity, all Releasee parties and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders, sponsors, and volunteers;

(2) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned herein from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.

I acknowledge that Releasee and their directors, officers, volunteers, representatives, and agents are NOT responsible for errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

I acknowledge that this activity may involve a test of a person's physical and mental limits and carries with it the potential for death, serious injury, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people, including, but not limited to, participants, volunteers, monitors, and/or producers of the activity. 

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.

I understand while participating in this activity, I may be photographed and/or taped via other recordings. I agree to allow my photo, video, audio or film likeness to be used for any purpose by the Releasee and assigns.

The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

SIGNATURES                                                                                                            EMERGENCY CONTACT INFORMATION

________________________________                                                               ________________________________

Releasor’s Signature                                                                                                   Name

________________________________                                                               ________________________________

Parent/Guardian Name and Signature                                                                      Mobile / Cellular Phone

 (If under 18 years old, Parent or Guardian must also sign.)

________________________________                                                               ________________________________

Date                                                                                                                               Alternate Name / Phone