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* Indicates required field

Parent/Guardian Name *

First

Last

Children's Names And Ages *

Total number of attendees *

Contact Information:

Email *

Phone Number *

Liability and Media Release

I agree to indemnify and hold harmless Integral Steps and Moxie Bread Co, its officers, employees, agents, consultants, subcontractors, insurers and representatives (collectively Integral Steps ), for any loss, damage, or injury to myself or my property in any way related to my participation in Integral Steps' and Moxie Bread Co's programs. This release of Liability applies to me as well as any of my children, personal representatives, assigns, heirs, and next of kin. I authorize Integral Steps and Moxie Bread Co to seek emergency medical assistance at my expense in a medical emergency.

Digital Signature of Participant (or parent/guardian) *

Date *

I give permission to Integral Steps and Moxie Bread Co to use any photographs, videotape, or other media record of my participation in this event for any lawful purpose, without compensation.

Digital Signature of Participant (or parent/guardian) *

Date *

I agree to receiving marketing and promotional materials

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