VERICO Cocktail Soirée 2023

Company Name *

—Please choose an option—

Office Name *

—Please choose an option—

Do you have a guest? *

—Please choose an option—YesNo

Declaration and Release

I do hereby state and declare that I am a participant in the VERICO Cocktail Soiree 2023 (the “Event”). I hereby:

• release Verico Financial Group Inc., its representatives, agents, affiliated and related companies (including, without limitation, parent, sister and subsidiary companies), the Event venue, advertising and promotional agencies, and any other party involved in the production or administration of the Event (collectively, the “Event Parties”) and each of their respective agents, representatives, employees, officers, directors, owners, successors, and assigns (collectively, the “Released Parties”) from any and all liability, for loss, harm, damage, injury, cost or expense whatsoever including, without limitation, property damage, personal injury and/or death that may occur in connection with the Event and/or my participation therein;

• understand, acknowledge and accept that my participation in the Event may involve danger and/or exposure to risks and hazards (including, without limitation, as may be due to contracting or being exposed to COVID-19 and/or the inherent risks of accidents due to the nature of the Event venue, Event activities and/or attendance by other individuals at the Event), whether arising from foreseeable or unforeseeable human error and negligence, and that, as a result, I may suffer damage to personal property, serious personal injury, illness or even death;

• warrant and represent that I have evaluated the nature, scope, and extent of the risks involved, and freely and voluntarily agree and assume any and all risks of personal injury, illness, death arising out of or connected with my participation in the Event;

• consent to the perpetual reproduction, publication, communication to the public by telecommunication and/or other use of my statements about the Event, my photograph and any other likeness worldwide, without further notice or compensation, in any publicity or advertisement carried out by or on behalf of Verico Financial Group Inc in any manner and media whatsoever (including without limitation print, broadcast or the internet).