The Results Map Experience Contract September 19th to September 22nd By signing this form, you give Kimberly Alexander Inc. permission to debit your account for the amount indicated on or after the indicated date. This is permission for payment as indicated below for The Results Map Experience, and does not provide authorization for any additional unrelated debits or credits to your account, unless otherwise noted. Upon receiving this authorization form, Kimberly Alexander Inc. will forward a welcome email with detailed information on the program. If you have chosen to do payments, all payments will be deducted on a monthly basis on the same dates as listed on the sign up form. Any credit card changes must be given to KA Inc. in a timely matter as to not delay recurring payments. I authorize Kimberly Alexander Inc. to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for The Results Map Experience, for the amount indicated above only, and is valid for the length of the contract. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. Please note: The Results Map Experience is confirmed at the time of purchase. Space is limited in this program. You may cancel this agreement for a full refund within five (5) days from the date of signature. No refunds will be given for cancellations after that 5-day grace period. Dates may not be changed once the participant is registered.RegistrantYour Name* First Last Title Email* Phone*Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Today's Date MM slash DD slash YYYY Lodging preference: Requested Suite mate2-bedroom suite/1 person per bedroom Wine Preference* Red White Rose Food Allergies and Preferences: Check all that apply* Gluten Free Celiac Vegan Vegetarian Other List any other food allergies or preferences here.Investment Option*If you choose the payment plan, you will still need to put down a $400 deposit. Then there will be three more scheduled payments of $950 that will automatically be deducted from your account on July 1st, August 1st, and September 1st. Full investment = $3,250 Payment Plan = $250 deposit; 3 payments of $1,000 Today's Total $0.00 Credit CardCard Details Cardholder Name Consent to the Waiver And Release Of Liability* I agree to the Waiver And Release Of LiabilityWAIVER AND RELEASE OF LIABILITY I hereby agree to observe and obey all rules, warnings, or other instructions given by an agent or representative of Kimberly Alexander Inc. or that of any third party involved in the activities associated with The Results Map Experience. I RECOGNIZE AND ACKNOWLEDGE THAT THERE ARE CERTAIN INHERENT RISKS ASSOCIATED WITH THE ACTIVITIES THAT ARE A PART OF THE RESULTS MAP EXPERIENCE AND I ASSUME FULL RESPONSIBILITY FOR PERSONAL INJURY TO MYSELF, AND FURTHER RELEASE AND DISCHARGE KIMBERLY ALEXANDER INC. FOR ANY AND ALL INJURY, LOSS, OR DAMAGE ARISING OUT OF MY PARTICIPATION IN THE RESULTS MAP EXPERIENCE, WHETHER CAUSED BY THE FAULT OF MYSELF OR A THIRD PARTY. I agree to indemnify, defend, and hold harmless Kimberly Alexander Inc. against all claims, causes of action, damages, judgments, costs, or expenses, including without limitation reasonable attorneys’ fees, which may in any way arise from or be caused by my participation in The Results Map Experience or my presence at any of the facilities utilized for The Results Map Experience. I further agree to pay for any and all damages to said facilities caused by any negligent, reckless, or willful actions by me. I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS DOCUMENT CONTAINS A RELEASE AND WAIVER OF LIABILITY AND I HEREBY AGREE TO IT VOLUNTARILY AND ON MY OWN FREE WILL.Consent to the Media Release Waiver* I agree to the Media Release WaiverI, the undersigned, do hereby consent and agree that Kimberly Alexander Inc, its employees, or agents have the right to take photographs, videotape, or digital recordings of me and to use these in any and all media, now or hereafter known. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to Kimberly Alexander Inc, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. By signing below I acknowledge that I have read the foregoing Liability Release Waiver and understand its contents; that I am at least eighteen (18) years old and fully competent to give my consent; That I have been sufficiently informed of the risks involved and give my voluntary consent in signing it as my own free act and deed; that I give my voluntary consent in signing this Liability Release Waiver as my own free act and deed with full intention to be bound by the same, and free from any inducement or representation. I represent that I am at least 18 years of age, have read and understand the foregoing statement and agree upon all conditions. Signature*CAPTCHA
