Participant Contact Information Congratulations on your participation in Moonshot! Please fill out the form below. "*" indicates required fields Step 1 of 5 20% Participant InformationStudent Name* First Last Phone*Email* School Counselor* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent or Guardian InformationParent or Guardian Name 1* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent or Guardian Name 2* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Medical InformationAllergies*If there are no allergies type none.Medical Conditions/Concerns for Mt. LeConte Hike and Travel*If there are no medical conditions/concerns type none.Do you have any dietary restrictions? If so, please list.*If there are no dietary restrictions type none. T-shirt SizeShirt Size (Mens and Womens Respectively)* XS S M L XL XXL Participant Release and Waiver Liability Consent to Participant Release and Waiver Liability*THIS PARTICIPANT RELEASE AND WAIVER OF LIABILITY (the “Release”) is made and executed as of the date stated below for the purpose of waiving and releasing MOUNTAIN WAYS, sometimes doing business as MOONSHOT, and LEADERSHIP SEVIER, INC., both Tennessee non-profit corporations, and each of their directors, officers, employees, agents and volunteers (collectively referred to herein as the “Nonprofits”), from any liability associated with the participation by the selected high school student identified below (the “Participant”) in events or activities hosted by the Nonprofits (the “Activities”). The undersigned, being at least eighteen years of age and the parent having legal custody or the legal guardian (collectively referred to herein as the “Guardian”) of the Participant, a minor child, for and in consideration of the services and opportunities furnished by the Nonprofits in connection with the Activities, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, hereby release, waive and discharge the Nonprofits as further stated herein from any and all liabilities, claims, demands or actions arising out of or related to the Activities. 1. Assumption of Risk. The Participant and the Guardian hereby understand and acknowledge that the Activities may include physical, outdoor and overnight experiences, including mountain hiking and camping and other outdoor sporting events. The Participant and the Guardian acknowledge the inherent risks associated with these outdoor events and activities, which may expose the Participant to the natural world, adverse weather, wild plants and animals and vigorous physical exertions (such as hiking to the summit of Mount LeConte in the Great Smoky Mountains National Park). Recognizing the inherent risks, the Participant and the Guardian hereby consent to the participation of the Participant in the Activities and expressly assume any and all risks, hazards and liabilities and take full responsibility for any and all personal injury, illness, death or damage or loss of personal property associated with the Activities. The Participant and the Guardian are responsible for the Participant’s own insurance coverage in the event of personal injury, illness, death or damage resulting from participation in the Activities. 2. Waiver and Release. The Participant and the Guardian hereby release, waive and forever discharge and hold harmless the Nonprofits, their directors, officers, employees, agents and volunteers, and their successors and assigns, from any and all liability, claims, demands and actions of whatever kind or nature, either in law or in equity, for any and all personal injury, bodily injury, illness, death or damage or loss of personal property, and any attorneys’ fees, costs or expenses (including but not limited to medical expenses), which arise or may hereafter arise from or relate to the participation in the Activities, including claims arising out of negligence. The undersigned understands and acknowledges that this Release discharges the Nonprofits from any liability or claims against the Nonprofits with respect to bodily injury, personal injury, illness, death, or property damage that may result from the Participant’s involvement in the Nonprofits’ Activities. The Participant and the Guardian further release, waive and forever discharge the Nonprofits from any claims arising from or related to any first-aid treatment or other medical services rendered in connection with an emergency during the Activities and give their consent for the Nonprofits’ agents or volunteers to provide, administer, or obtain medical treatment for the Participant in the Nonprofits’ discretion. 3. Insurance. The Participant and the Guardian affirm that the Participant is covered by primary medical insurance and understand that they are responsible for the Participant’s medical bills if injury occurs. The Participant and the Guardian understand that the Nonprofits do not assume any responsibility for or obligation to provide the Participant with financial or other assistance, including but not limited to medical, health or disability benefits or insurance of any kind. The Participant and Guardian expressly waive any claims for such compensation or benefits. 4. Photographic Release. The Participant and the Guardian grant and convey to the Nonprofits all right, title, and interest in any and all photographs, images, video or audio recordings of the Participant or his or her likeness or voice made by or for the Nonprofits in connection with the Activities, including but not limited to any royalties, proceeds, or other benefits derived from such photographs or recordings. The Participant and the Guardian understand and confirm that by signing this document they are giving up considerable legal rights. The Participant and the Guardian agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Tennessee and that this Release shall be governed by and interpreted in accordance with the laws of the State of Tennessee. The undersigned has carefully read the Release and understands its contents and has signed this Release freely and voluntarily and under no duress of any kind. In the event any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected. I agree to the Participant Release and Waiver of Liability.Parent and/or Guardian Signature*By typing your name below, you are signing this release and waiver electronically. Parent Phone Number*Participant Name* First Last Participant Age*Date of Release* MM slash DD slash YYYY