Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact Person and Phone Number *

First Name

Last Name

Phone

(###)

###

####

Question 1: Do you want to participate in a 1-Day wade/walk trip?

Yes

No

Question 2: Do you want to participate in the 2 ½ Day Ruby River wading trip?

Yes

No

Question 3: Do you want to participate in the 2-Day Missouri River drift boat trip?

Yes

No

Question 4: Do you want to participate in the Women’s only 2-Day Missouri River drift boat trip?

Yes

No

Question 5: Do you have any food allergies and/or special food consumption requirements?

Yes

No

Question 6: If all trips are currently full, do you want to be placed on a standby list?

Yes

No

RELEASE AGREEMENT *

Montana, Inc. programs (the “Programs”), I, the undersigned, in acknowledgment that I am doing so entirely upon my own initiative, risk and responsibility, do hereby, for myself, my heirs, executors, and administrators, agree to remise, fully release, hold harmless, and forever discharge Mending Waters Montana, Inc. and each of their officers, directors, employees and volunteers, acting officially or otherwise, jointly and severally from any and all claims, demands, actions or causes of actions, on account of my death or on account of any injury to me or my property which may occur from any cause whatsoever, including, without limitation, the negligence of any Releasee, or the consumption of alcohol by me or others, while participating, or as a result of my participation, in the Programs. I fully understand the risks and dangers involved in fly fishing, particularly when wading or boating, and related fly fishing activities. In the event of injury to me while participating in the Programs, I hereby authorize any of the Releasees to seek on my behalf any necessary medical attention. If any term or other provision of this Release Agreement is determined by a court of competent jurisdiction to be invalid, illegal or incapable of being enforced by any rule of law or public policy, all other terms, provisions and conditions of this Release Agreement shall nevertheless remain in full force and effect. I have read this Release Agreement and fully understand the consequences of this Release Agreement, including that it releases the Releasees from any and all liability on account of any injury to me or to my property. I further attest that I am over 18 years of age and possess the capacity to enter into this Release Agreement.

I have read this Release Agreement and fully understand the consequences of this Release Agreement, including that it releases the Releasees from any and all liability on account of any injury to me or to my property. I further attest that I am over 18 years of age and possess the capacity to enter into this Release Agreement.

MEDIA RELEASE *

MENDING WATERS MONTANA, INC., [MWM] FORM OF CONSENT FOR USE OF PERSONAL INFORMATION AND VISUAL IMAGES MWM is a 501(c)(3) non-profit charitable organization registered with the State of Montana. Mending Waters Montana, Inc. is dedicated to the physical and emotional rehabilitation of active military service personnel and Veterans through fly fishing and associated activities including education and outings. Consent Form In consideration of the opportunities and services offered by MWM and my participation in them, I agree to permit MWM to use pictures, photographs, and/or other visual images of me, and narrative material about me and my participation in the MWM programs, for its educational and promotional efforts and its website. I assign all rights, title, and interest in and to the material and the copyright of the materials to MWM. I waive any right to inspect and approve the photos, or other images and narrative materials about me, and any advertising and promotional copy with which they are connected. I understand that the circulation of such materials could be nationwide and that there will be no compensation to me for the use of such materials by MWM. I waive any claim and all causes of action I may have against the MWM for its use of the pictures, photographs or visual images and narrative material. The rights and protections granted in this document may be exercised by MWM at any time without limitation. My participation in the programs of MWM is voluntary and in my private capacity.

I have read this document and intend to be bound by it.

Date *

MM

DD

YYYY