Assumption of Risk, Waiver of Liability, and Indemnification Agreement

Andre Boucher and A&a Balloon Rides, LLC

Notice: Please Read this Document carefully before signing.

I understand that the hot air balloon activities offered by A&a Balloon Rides, LLC can potentially be dangerous, and involve the risk of injury or death to myself, and damage to my property. I understand that such risks include, but are not limited to: (a) loss of or damage to personal property; (b) bodily injury or fatality; and (c) accident or illness in remote places without medical facilities. I understand that no medical benefits will be provided to me during these ballooning activities, and that I and/or my insurance shall be solely liable to pay for any medical expenses incurred on my behalf.

I certify that I have no physical or mental defect or medical defect or medical condition that prevents me from participating in any hot air balloon activities, including but not limited to pregnancy or heart, back, or altitude problems.

I agree to follow all instructions of the pilot in connection with this hot air balloon activity. I understand that my failure to do so may jeopardize my safety and the safety of the pilot, other passengers, and other persons.

Being aware of the risks involved, I am voluntarily applying to participate in hot air balloon flights and associated activities operated by A&a Balloon Rides, LLC. I understand that the waivers, indemnifications, releases, and assumptions of risk herein contained are consideration and part payment for the right to participate.

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Without limiting the generality of the foregoing, I herby irrevocably release A&a Balloon Rides, LLC, its employees, agents, representatives, contractors, subcontractors, successors, heirs, assigns, affiliates, and legal representatives (the “Released Parties”) from, and hold them harmless for, all claims, rights, demands or causes of action whether known or unknown, suspected or unsuspected, arising out of the ballooning activities, which I or my successors, heirs, or assigns may have against the Released Parties in connection with ballooning activities with A&a Balloon Rides, LLC, and I agree to make no claims against or sue the Released Parties for injuries, death, or property damage that is caused due to the ordinary negligence of the Released Parties or any dangerous conditions of any property upon which the ballooning activities may take place. I also agree to hold harmless, defend, and indemnify A&a Balloon Rides, LLC (that is, defend and pay any judgment and costs, including investigation costs and attorneys’ fees) from and all claims rights, demands or causes of action whether known or unknown, suspected or unsuspected, arising out of the ballooning activities, which any co-participants, rescuers, or others may have against the Released Parties in connection with ballooning activities with A&a Balloon Rides, LLC, including those arising from the inherent risks of ballooning activities or the ordinary negligence of the Released Parties or any dangerous conditions of any property upon which the ballooning activities may take place.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND A&A BALLOON RIDE, LLC, AND I HAVE SIGNED IT OF MY OWN FREE WILL. I FURTHER ACKNOWLEDGE THAT MY QUESTIONS REGARDING BALLOONING HAVE BEEN ANSWERED SATISFACORILY AND I HAVE BEEN BRIEFED REGARDING PASSENGER SAFETY.

DATED: ___/___/_____ Witness: _____________________________

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