RELEASE FORM Prize: Pair – Ottawa SENATORS Game – APR. 10 Date: ___________________ WINNER’S DECLARATION I, ____________________________________ (First/last name of the winner), residing at the address indicated at the bottom of this form, declare that: 1. I meet all eligibility requirements and acknowledge I have read, understood and complied with the attached contest rules or the station’s general contest rules as applicable (the “Rules”), notably in connection with my participation in the Contest and any acceptance and use of the prize. 2. I have reached the age of majority in my place of residence. (If not, the DECLARATION OF THE PARENT OR LEGAL GUARDIAN TO A MINOR must be filled out, for contests open to minors.) 3. I am not an employee of Bell Media Inc., of its agents, parent, affiliated or related companies, subsidiaries, divisions, prize sponsors, promotional and advertising agencies or of any other entity involved in the development, production, administration, or fulfilment of the applicable Contest (“Contest Parties”), nor am I such employee’s parent, sibling, child or domiciled with such employee. 4. I am eligible to win the prize offered to me if I can correctly answer the following mathematical question: (5 + 7 ) + ( 10 ÷ 2 ) – 3 = 5. If I correctly answer the above mathematical question, I accept the prize as awarded in accordance with the conditions inherent to its use and the Rules. 6. I hereby authorize Bell Media Inc., and any Contest Sponsor where applicable, to broadcast, publish, disseminate and otherwise use my name, city/town/village and province/territory of residence, photograph, likeness, sobriquet and voice, in connection with any promotion and/or publicity, and/or for general news, entertainment and/or information purposes at no additional compensation to me, beyond the awarding of or participation in the prize. 7. I understand that I may sign this release using an electronic signature, and that I consent to the use of an electronic signature by signing electronically. LIABILITY WAIVER (Read carefully) I HEREBY ACCEPT THE PRIZE AS OFFERED AND RELEASE THE CONTEST PARTIES FROM ANY AND ALL LIABILITY OR DAMAGES INCLUDING, WITHOUT LIMITATION, FOR BODILY INJURY OR DEATH ARISING OUT OF MY PARTICIPATION IN THE CONTEST AND/OR MY RECEIPT AND USE OF THE PRIZE. I WAIVE ALL RIGHT TO MAKE ANY CLAIMS WHATSOEVER, INCLUDING TAKING ANY LEGAL PROCEEDINGS, AGAINST THE CONTEST PARTIES WITH RESPECT TO THE SAME. I ACKNOWLEDGE THAT UPON AWARDING OF THE PRIZE, THE OBLIGATIONS TYPICALLY BORNE BY THE PROVIDER OF SERVICES OR GOODS BECOME THAT PROVIDER’S RESPONSIBILITY. I declare that I have carefully read this release, understand its content, and consent to it of my own free will. This release also binds my heirs and successors. IN WITNESS WHEREOF, I have signed at ________________________________ (name of the city/municipality where this declaration is signed). Signature of Winner Signature of Witness with age of majority Date (Day/Month/Year) Date (Day/Month/Year) Winner’s address: Name: Address: City: Province: Telephone: Postal Code: