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Gray Quarry, Inc.
DIVE SHOP AFFILIATED INSTRUCTOR ACKNOWLEDGEMENT

GRAY QUARRY, INC.


DIVE SHOP INSTRUCTOR ACKNOWLEDGEMENT


Instructor Name: _____________________________________

Dive Shop Name: _____________________________________


The Instructor named above hereby acknowledges and agrees that before Instructor can conduct any

training at the Gray Quarry, the following requirements must be met:

1. Ensure a signed Dive Shop Agreement* is on file for the current calendar year (one

agreement per Dive Shop).

2. Signed Instructor Acknowledgement* for the current calendar year.

3. Proof of current Instructor liability insurance (through Dive Shop or individual policy) that also

shows Gray Quarry as additional insured.

4. Proof of current liability insurance for any Dive Professional (e.g. Divemaster) assisting the

Instructor.

5. Signed Liability Release* for:

a. Instructor,

b. All Dive Professionals assisting, AND

c. All students/other divers.

6. Collected Pass Fees for:

a. Instructor (covered if Dive Shop purchases Annual Pass), AND

b. All students/other divers.

* To be completed electronically at www.grayquarry.com.


The Instructor named above acknowledges and agrees to comply with the current Gray Quarry Rules for

Professional Instructors and Dive Professionals posted on the Instructors & Dive Shop Information page

at www.grayquarry.com. Instructor acknowledges that Gray Quarry may modify these requirements from

time-to-time by posting updated guidelines on the website.


The Instructor named above acknowledges and agrees to abide by and to ensure that all divers/students

with Instructor’s group abide by the Gray Quarry Guidelines and Safety Information posted on the Gray

Quarry website at: https://grayquarry.com/reservations. Instructor acknowledges that Gray Quarry may

modify these requirements from time-to-time by posting updated guidelines on the website.


Instructor Signature: _________________________________


Date: _________________________________

First Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
First Instructor's Age Acknowledgment*
First Instructor's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Instructor's Signature*
Second Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Third Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Fourth Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Fifth Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Sixth Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Seventh Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Eighth Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Ninth Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Tenth Instructor's Name
First Name*
Middle Name
Last Name*
Phone*
Instructor's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Shop Affiliation
Which dive shop are you affiliated with? *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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