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Atlantic Divers

795 Route 109

Cape May, NJ 08204

609.884.0330

www.atlanticdivers.com

I

am responsible for my own actions and use of Scuba equipment, including such rented from Atlantic Divers L.L.C. In consideration for my being permitted to participate in this (these) scuba trips(s)/activities, I hereby acknowledge and agree that I am financially responsible for expenses, including medical expenses, resulting from injuries sustained during this (these) trip(s), and I RELEASE AND GIVE UP ANY AND ALL CLAIMS AND RIGHTS WHICH I MAY HAVE against Atlantic Divers L.L.C., Peter Barto, Gene Peterson, Tom Stocker, all employees and dive leaders, including instructors, dive masters, assistants and safeties of Atlantic Divers, for personal injury, property damage, wrongful death or any other loss I may sustain as a result of engaging in any scuba diving related activity with Atlantic Divers L.L.C..


I further understand and agree that SCUBA DIVING is DANGEROUS whether engaged in depths above or below the recommended 130 foot limitation for sport diving activities and I FULLY UNDERSTAND AND ACCEPT ANY AND ALL RISKS THAT SUCH ACTIVITIES MAY INVOLVE.


I AM BOUND BY THIS RELEASE/WAIVER. ANYONE WHO SUCCEEDS TO MY RIGHTS AND RESPONSIBILITIES SUCH AS MY HEIRS OR THE EXECUTOR OF MY ESTATE IS ALSO BOUND.


This release/waiver is made for the benefit of Atlantic Divers L.L.C., Peter Barto, and Gene Peterson, Tom Stocker, Mike Butterfield, and all employees and dive leaders, including instructors, dive masters, assistants, and safeties of Atlantic Divers L.L.C. and to all who succeed to their rights and responsibilities, such as their heirs, estate executors, or representatives.


I UNDERSTAND AND AGREE THAT THIS MEANS THAT IF I AM INJURED OR DIE IN A SCUBA DIVING RELATED INCIDENT, I AM GIVING UP MY RIGHTS AND/OR THE RIGHTS OF MY HEIRS, REPRESENTATIVES, EXECUTORS OR SUCCESSORS TO SUE ATLANTIC DIVERS, PETER BARTO, GENE PETERSON, AND ALL EMPLOYEES AND DIVE LEADERS, INCLUDING INSTRUCTORS, DIVE MASTERS, ASSISTANTS AND SAFETIES OF ATLANTIC DIVERS L.L.C. FOR DAMAGES OR ANY FORM OF COMPENSATION.


I understand and give permission for this waiver to be used to defend Atlantic Divers L.L.C., Peter Barto, Gene Peterson, Tom Stocker, Mike Butterfield, and all employees and dive leaders, including instructors, dive masters assistants of Atlantic Divers L.L.C.


I hereby acknowledge that I have read the foregoing paragraphs and understand everything set forth within it. I HAVE BEEN FULLY ADVISED AND AM AWARE OF THE POTENTIAL PERSONAL DANGERS INCIDENTAL TO ENGAGING IN SCUBA DIVING ACTIVITIES AND HAVE CAREFULLY CONSIDERED THE LEGAL CONSEQUENCES OF SIGNING THIS RELEASE/WAIVER.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Second Participant's Signature*
Third Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Third Participant's Signature*
Fourth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
Tenth Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Certification Agency *

Level and Certification Number *

Dive Insurance Carrier and Policy Number

Medical Insurance Carrier and Policy Number

Blood Type *

Allergies/ Conditions

Any Diving Related Injuries in the last 5 years? *
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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