Date *

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DD

YYYY

Participant's Name *

First Name

Last Name

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Are Any Participants Under Age 18? *

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Yes

Items to be: *

Shipped

Picked Up

Address *

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Address 2

City

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Phone *

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Release *

By checking the box below I certify that I, the participant, am 18 years of age or older; or that I am the legal parent/guardian of a participant under the age of 18, and I hereby agree that in consideration of Liquid Light Glass allowing me to use their facilities, materials and equipment, that I hereby remise, release now and forever, Liquid Light Glass, Baca Street Studios and/or its affiliates, subsidiaries and assigns of any and all claims, damages and injuries to myself, to my property, which arise out of or in any way related to any activities on the premises of Liquid Light Glass, and/or Baca Street Studios, from any such claims or allegations which I might now have, may have, or any of my heirs, successors or assigns.

I Agree to the Terms of this Release