Name *

First Name

Last Name

Date of Birth *

Must be 21+

MM

DD

YYYY

I have read and Agree to the Waiver & Release Above *

Yes

I confirm I am at least 21 years of age. *

Yes

Media Release *

I grant Three Sip Society, LLC permission to use photos or video of me taken during the event for marketing purposes.

Yes

No

Date *

MM

DD

YYYY