The undersigned, as a condition of attending the Pain on the Plains event by Midwest Alternatives in the city of Lincoln, State of Nebraska the 7th day of the month of August, the year 2010, hereby waives all liability as against Midwest Alternatives, its officers, sponsors, presenters and agents; and all persons involved in arranging, producing, planning, financing, and otherwise connected to the said event.
The undersigned further certifies that he or she meets the following conditions:
- Is at least twenty one years of age;
- Is in good mental and physical health;
- Has no personal or moral objection to frank discussions of alternative sexuality, nudity, bondage, discipline, sadism, masochism, or any other lifestyle freely entered into by the participants;
- Has had an opportunity to discuss with the sponsors of this event any and all concerns, doubts, or reservations he or she may have concerning the event and has had all such resolved to his or her satisfaction;
- Has had an opportunity to inspect the premises and equipment and is satisfied that the premises and the circumstances of the presentation are safe.
The undersigned further indemnifies and holds harmless all persons connected with this presentation from any and all damages, including but not limited to:
- Physical injury
- Psychological, psychiatric, or other mental health damages
- Damage to social or professional status and standing
- Damage to personal or professional relationships;
- Injury to or loss of personal property;
- Any and all other damages which may arise from this presentation or any resulting social or other function, formal or informal.
I hereby certify that I am not an employee of any law enforcement agency, or if I am; I am attending this event solely for my personal enjoyment and not as part of any investigation.
I certify that I am not a member of the media, or if I am, I am attending this event solely for my personal enjoyment and not as part of any investigation or gathering of information. I will not use or release any such information in any way without the express written permission of Midwest Alternatives.
I hereby certify that I am not a member or agent of any political or religious organization which has stated aim of opposing this or similar events, or that if I am, I am attending solely for my personal enjoyment and will in no way impede or disturb the activities of this event, it’s attendees or organizers, and will not use or release any information regarding this event or attendees.
I hereby certify that I have read the Dungeon Rules and that I understand and will comply with them in their entirety.
I agree that everything that I observe here will be kept in strict confidence. I recognize this as a contractual obligation and that I will do nothing to jeopardize the privacy and/or identities of any other attendee.
The undersigned certifies that he or she has read this Waiver, understands it, and has signed it freely, knowingly, and voluntarily.
The Pain on the Plains 5 information will be provided in the confirmation letter.
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Please send this completed registration form with payment to:
Midwest Alternatives
PO Box 57422
Lincoln, NE 68505
Note: Registration is NOT complete until your registration form is received and check clears.
Legal Name: ________________________________________________
Screen Name: _______________________________________________
Additional Attendees Legal Names: _______________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
E-mail Address: ______________________________________________
Address: ____________________________________________________
City: ________________________ State: _______ Zip: _______________
DO NOT SIGN FORM. Registration must be Signed and Witnessed at Event:
Registrant Signature: _____________________________________________________
Date: __________________________________________________________________
Additional Attendee Signature: _____________________________________________
Date: __________________________________________________________________
Additional Attendee Signature: _____________________________________________
Date: __________________________________________________________________
Additional Attendee Signature: _____________________________________________
Date: __________________________________________________________________
Additional Attendee Signature: _____________________________________________
Date: __________________________________________________________________
Additional Attendee Signature: _____________________________________________
Date: __________________________________________________________________
(scene and/or screen names are not sufficient)
REGISTRATION IS NOT COMPLETE UNTIL A COMPLETED
REGISTRATION FORM IS RECEIVED CHECK CLEARS.
