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Advance Release Ultra-Hazardous Activity

----------------------------, referred to as PARTICIPANT, and -------------------------------, referred to as PROVIDER, agree:

PROVIDER offers the following activity:

The parties agree that:

(a) this activity is by its nature hazardous and despite the exercise of all due care, personal injuries or death may occur in this activity;

INITIAL HERE AS TO paragraph (a) ____________

(b) that PROVIDER has given PARTICIPANT a full and adequate opportunity to ask questions and obtain a full and complete explanation of the risks of the activity;

INITIAL HERE AS TO paragraph (a) ____________

(c) that the PARTICIPANT, on behalf of PARTICIPANT and the heirs, successors and assigns, herewith releases PROVIDER from any and all liability for personal injuries, consortium or other claims arising out of participating in the activity, except for any action resulting from willful and malicious actions by PROVIDER.

INITIAL HERE AS TO paragraph (c)

Dated: ____________.

_______________________________

Witnesses:

_______________________________

_______________________________