G5 FIRE WAIVER OF LIABILITY

I, ______________________________________, wish to perform at Gallery 5 at 200 W Marshall St Richmond, VA during the First Fridays Art Walk for the year ________.

I hereby undertake and agree that I shall at all times hereafter on behalf of myself, my heirs, and assigns and my legal representative indemnify and keep indemnified any of G5 Fire’s officers, members, servants and agents, successors and assigns or any one or more of them from and against claims, actions, suits, damages, expenses and costs of every nature of description whatsoever which may be made or incurred by reason of or in consequence of:

a) any accident, incident, mishap, injury or loss caused or occasioned either wholly or partially by my participation or non-participation in the activity;

b) the manner in which the activity was so organized or conducted;

or

c) my treatment in the course of the activity.

I accept full responsibility and liability for my actions and any consequence of my actions. I agree to compensate any damages that might come as result of my actions. I agree to consider any guidelines or recommendations given by the G5 Fire Safety Team. I agree to compensate any damages to any party that might come as result of my actions.

I understand that performing with fire may be hazardous to me. I hereby expressly and specifically assume the risk of injury or harm in these activities and release Gallery 5 and G5 Fire from any and all liability for injury, illness, death or property damage resulting from my activities at Gallery 5.

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Performers Signature

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Performers name (printed)

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Address

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Cell Phone 1 Cell Phone 2 Home Phone

Emergency Contact Information

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Name

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Relation

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Cell Phone 1 Cell Phone 2 Home Phone