Domino's Pizza Eating Contest

Name

First Last

Date Of Birth

Age

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Emergency Contact

Emergency Contact Phone Number

Eligibility and Voluntary Participation(Required)

I certify that I am at least 18 years old and that the identification I presented is valid. I understand that my participation in the Domino's Brunswick Pizza Eating Challenge is completely voluntary. I have received or had an opportunity to review the official contest rules understand those rules, and agree to follow all instructions given by contest judges, staff members, safety personnel, and event organizers. I understand that I may stop participating at any time. I also understand that a judge or safety monitor may stop my participation at any time if that person believes continuing may be unsafe.

Yes

Acknowledgement of Risks(Required)

I understand that eating food rapidly involves serious and potentially life-threatening risks. These risks include, but are not limited to: - Choking or airway obstruction - Aspiration of food or liquid - Difficulty breathing - Nausea, vomiting, or regurgitation - Abdominal pain, gastrointestinal distress, or injury - Allergic reactions or food sensitivities - Burns from hot food - Dental, mouth, throat, or esophageal injury -Dizziness, fainting, dehydration, or loss of consciousness - The need for emergency medical treatment or hospitalization - Permanent injury, disability, or death I understand that emergency personnel may not be able to prevent every injury or medical emergency.

Yes

Health and Allergy Certification(Required)

By signing this document, I certify that: I am physically capable of participating in a rapid-eating competition. I do not have a known condition that makes chewing, swallowing, or rapid eating especially dangerous. I am not currently experiencing illness, breathing difficulty, swallowing difficulty, nausea, or gastrointestinal distress. I am not under the influence of alcohol, cannabis, illegal drugs, or any medication or substance that could impair my judgment, coordination, or ability to swallow safely. I have considered whether I should consult a healthcare professional before participating. I accept responsibility for identifying ingredients that may affect me.

Yes

Food allergies or medical conditions disclosed by participant(Required)

I understand that disclosing a condition does not require the organizers to permit me to participate. The organizers may decline or stop my participation for safety reasons

Photo and Video Authorization(Required)

Yes - I authorize the event organizers and Domino's to photograph, record, and use my name, image, voice, and contest participation for lawful advertising, l media, publicity, and promotional purposes without additional compensation.

No - I do not authorize promotional use of my name, image, voice, or likeness, except for appearance in general crowd or event footage where legally permitted.

Particpant Acknowledgment(Required)

I confirm that: - I have read this entire document. - I understand that it affects my legal rights. - I had an opportunity to ask questions before signing. - I am signing voluntarily and without pressure. - I understand that signing this document is required to participate

Yes

Name

First Last

Date

Domino’s Pizza Eating Contest

Domino's Pizza Eating Contest