BLACK HOLE WEEKEND REGISTRATION
Mid America Fists In Action, Inc.
P.O. Box 25107  Chicago, IL 60625-0107
Phone: 312.401.8893
Website: http://www.mafiaff.org Contact Email for Assistance: Blackhole@mafiaff.org
Email address *
What is your year of Birth? *
Your answer
Party Date *
Directions provided after registration. (PayPal no need for the $, enter fee number only. Next screen use your PayPal account if you have one or click near bottom to pay by credit/debit card after entering the amount you are paying.)
Required
First Name *
Your answer
Last Name *
Your answer
Address *
Street address including unit number
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Country *
Your answer
Phone Number *
Domestic: XXX-XXX-XXXX or International: +-X-XX-XXXX-XXXX
Your answer
Member of Fisting, Leather or Fetish Club
List your club(s) below
Your answer
Voluntary Participation, Execution of Knowledge, Indemnity, Assumption of Risk, and Hold Harmless *
I am freely and voluntarily choosing to attend and participate in this event and to view and/or participate in activities that I know are adult oriented Sexual Fetishes. I understand that these activities involve certain risks including, but not limited to, the possible negligent or reckless conduct of other participants. I have carefully read this document. I fully understand the contents. I am aware that by signing this document I release liability and bind a contract between M.A.F.I.A. and myself. I am giving up my legal rights and remedies and as good and valuable consideration for admission to this event. I agree to indemnify and hold harmless Mid America Fists In Action Inc., and those individuals and entities described in this document, from any loss, liability, injury, damage or cost that they may occur or that they may incur due to my presence or my actions at the event, whether caused by my negligence or otherwise. I am aware that these activities can be extremely hazardous. I voluntarily am participating in these activities with full understanding of the hazards involved.
Required
Release of Legal Claims or Charges and Agreement of Rules and Regulations *
As consideration for being permitted by Mid America Fists In Action Inc. to enter the event, and to view and participate in these activities, and to use the facilities and equipment being provided. I agree to the following. I, myself, a person on behalf of me or through me will make any claim against or sue the following: *Mid America Fists In Action Inc.* Affiliates of Mid America Fists In Action Inc.(including, but not limited to, the officers, directors, members, agents, employees, volunteers, promoters, sponsors, contractors, the property owners, lessors or suppliers of the premises, lessors or suppliers of any equipment used in connection with the event) for the following: Any injury or damage suffered by me at any time during my presence at the event or because of my participation in any activities at the event. I hereby release, waive and forever discharge them, their heirs, administrators, executors, and assigns, from any and all claims, demand, actions or rights of action, of whatever kind or nature, either in law or in equity, arising from or by reason of my attendance at or participation in the event or activities.
Required
Optional Opt Out of Mafia Notices *
If you would not like to receive either physical mail or email about upcoming MAFIA Parties and Activities
Required
How did you hear about MAFIA
Share the source where you found us
Your answer
Rules and party location are provided after payment is received *
Required
Electronic Signature for this form *
I have agreed to submit this Black Hole Weekend registration by electronic means.
Required
NEXT CLICK SUBMIT at the bottom of this form to Complete Your Payment
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms