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Licensed Skydivers please complete.

Skydive Central New York, LLC

WARNING!

I understand that skydiving, parachute jumping, and all of their related activities can be dangerous, and there are risks involved in my participation. I understand and acknowledge that I can be seriously and permanently injured or even killed as a result of my participation in skydiving, parachute jumping, flying and related activities.

NO INSURANCE

I also understand and acknowledge that I am not covered by any insurance provided by, or on behalf of, any of the released parties, as they are defined in this agreement.

By my signature below, I am indicating that I have read and fully understand the above WARNING.

July 23, 2018

 

Skydive Central New York, LLC

WAIVER, RELEASE OF LIABILITY, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT AND COVENANT NOT TO SUE

THIS IS A LEGAL DOCUMENT

It is recommended and highly encouraged that you seek competent legal counsel before agreeing to, initialing or signing this waiver, release of liability, hold harmless and indemnification agreement and covenant not to sue. My initials or signatures, where indicated, are my acknowledgment of the contents of the paragraph preceding my initials or signature, and by said initials or signature I am indicating that I have read the subject preceding paragraph, and that, subject to the further terms of this Waiver, Release of Liability, Hold Harmless and Indemnification Agreement and Covenant Not to Sue (hereinafter sometimes referred to in this document as the Agreement,) I fully understand, and agree to be bound by, its contents.

FAMILIARITY WITH THE ENGLISH LANGUAGE

I know how to read, write, and understand the English language, sufficiently to understand this document and to fully appreciate its nature and the consequences of each and every covenant contained in this Agreement and the consequences of my consent thereto.

DEFINITIONS

As used in this Agreement, the term Skydiving, Parachute Jumping and Related Activities whenever and wherever used in this document, shall be deemed to include, but not to be limited to, all activities in any way related to skydiving, parachuting, parachute packing, parachute use, free-fall, wing suit use, canopy flight, aircraft passenger operations, aircraft flight and ground operations, motor vehicle and watercraft operations and any and all activities occurring on or about any location from which, or to which, skydiving or parachute jumping is taking place, has taken place, is contemplated or is intended to take place, or may, unintentionally, take place, and including but not limited to Skydiving, Parachute Jumping and Related Activities at or in the area at, around and/or above the Whitford's Airport. I agree that it is impossible to contemplate all activities that may be included in the term Skydiving, Parachute Jumping and Related Activities and that this term shall, therefore, be interpreted broadly and inclusively and not be limited to the above-stated activities.

I Agree

Released Parties

As used in this Agreement, the term Released Parties, whenever and wherever used in this document, shall be deemed to include, individually and collectively Skydive Central New York, LLC, Whitfords Airport, LLC, Michael F. Burgess, individually, Jeni L. Burgess, individually, John A. Whitford, individually, Jeffery R. Whitt individually, USPA and manufacturers, distributors and dealers of skydiving equipment, the fixed base operators, drop zone owners and operators, owners, lessors and lessees of any airport or land or other facility which may, in any way, be utilized in furtherance of the Skydiving, Parachute Jumping and Related Activities the manufacturers, owners, lessors, lessees, drivers, and pilots of any aircraft, and the manufacturers, owners, lessors, lessees, drivers of any other vehicle. Any and all directors, officers, owners, shareholders, members, volunteers, employees, agents, independent contractors, heirs, representatives, successors and assigns of the aforementioned persons and entities. I further understand and acknowledge that Whitford's Airport acts only as a lessor to Skydive Central New York, LLC, and that there is no other business relationship, nor is there any principal-agent relationship, between it and any of the other Released Parties.

I Agree

CONSIDERATION

For and in consideration of my being permitted by the hereinbefore defined Released Parties to make one or more jumps and to participate in the hereinbefore defined Skydiving, Parachute Jumping and Related Activities, involving one or more of the hereinbefore defined Released Parties, and the use of the associated facilities and equipment, and for other good and valuable consideration the receipt and sufficiency of which is hereby acknowledged, I hereby agree to be bound by all of the provisions of this agreement.

VOLUNTARY CHOICE

I have come to participate in Skydiving, Parachute Jumping and Related Activities of my own free will and not due to any inducement or duress. I understand that prior to being allowed to make a parachute jump in any way involving the Released Parties, or any of them, I must understand and agree to be bound by all of the provisions of this Waiver, Release of Liability, Hold Harmless and Indemnification Agreement and Covenant Not to Sue. I further understand that this is not the only location where I may make a parachute jump, nor are the methods employed by any or all of the Released Parties the only methods available to enable me to make a parachute jump, and that if I do not fully understand and agree to be bound by all of the provisions of this Agreement, then I shall not be permitted to make a parachute jump at this location, but there may be other locations at which I may make a parachute jump.

I Agree

NATURE OF THE ACTIVITY AND ASSOCIATED RISKS

I understand that skydiving, parachute jumping and related activities are dangerous activities which can and sometimes do result in bodily injury or death to participants. I understand that I will be parachuting from an aircraft in flight, which is a dangerous thing to do. I understand that I may be injured or killed, even if I do everything I was trained to do, through my own fault or negligence, or through the fault or negligence of others, or through the failure of a component or components of the parachute systems, which I may from time to time use in Skydiving, Parachute Jumping and Related Activities, to function properly. I further understand that there is not now, nor will there ever be, a perfect parachute system, a perfect airplane, a perfect pilot, a perfect parachute packer, a perfect instructor, or a perfect student, and that each of the foregoing and others involved in the process of enabling me to make a parachute jump can, and likely will, fail to perform as intended. The risks involved include, but are not limited to, partial or complete failure of the parachute system, or any of its components, partial or complete failure of the airplane, and/or of other equipment utilized for Skydiving, Parachute Jumping and Related Activities, hard parachute openings, inadvertent or premature parachute openings, improper parachute packing, falling out of the harness in the air, hard landings, mid-air collisions between participants, mid-air collisions between a participant and an aircraft, mid-air collisions between a participant and another parachute canopy or associated components, collisions between a participant and a person or object on the ground, risks arising because of air to ground or air to air communication failures, wind and/or weather changes, the negligence and/or gross negligence of pilots, instructors, parachute packers, other parachutists, other parachutist students, spectators, rescue personnel, and others in any way involved with my Skydiving, Parachute Jumping and Related Activities, or any of them, or of others who are present at the location where my Skydiving, Parachute Jumping and Related Activities occur, weather related causes, negligent rescue causes, and any and all other causes which may or may not be known at this time but which may become known in the future and which may cause, directly or indirectly, my injury or death. I understand that the aircraft which is used for my Skydiving, Parachute Jumping and Related Activities may be operated under regulations which permit its engines to be operated in excess of the manufacturers recommendations of time between overhauls (TBO) and that the aircrafts engine or engines may, in fact, exceed the manufacturers recommended TBO. Each time, prior to participating in any Skydiving, Parachute Jumping and Related Activities, I will determine the identity of each piece of equipment and its manufacturer that I will use for that participation, and if I have not done so, I will not participate in the Skydiving, Parachute Jumping and Related Activities. Each time I do participate in Skydiving, Parachute Jumping and Related Activities, I agree that it is conclusive proof that I have so determined the identity of each such piece of equipment and its manufacturer and that knowing such identity and the identity of the manufacturer, I agree that the terms of this Agreement are and shall be in full force and effect, with respect to each piece of equipment used for that participation and with respect to each manufacturer thereof.

I Agree

AWARENESS OF RISKS INVOLVED

Do you realize that you can die as a result of your participation in any and all phases of Skydiving, Parachute Jumping and Related Activities?

I Agree

Do you realize that minor and major injuries can result from your participation in any and all phases of Skydiving, Parachute Jumping and Related Activities?

I Agree

Are you willing to risk your life while participating in Skydiving, Parachute Jumping and Related Activities, regardless of fault from causes, including, but not limited to, negligence of one or more of the persons involved in these activities?

I Agree

Are you willing to risk major or minor injury to any or all parts of your body, or death, while participating in Skydiving, Parachute Jumping and Related Activities, regardless of fault, including, but not limited to, negligence and gross negligence of one or more of the persons or entities involved in these activities?

I Agree

ASSUMPTION OF RISK

With full knowledge and understanding of the foregoing, and with full understanding of the potential dangers and possible consequences of my participation in Skydiving, Parachute Jumping and Related Activities, I hereby, of my own free will and without inducements, promises or statements other than those contained in this Agreement, expressly assume all risks of any nature whatsoever for any death, injury or other damages to myself, my property, and the person and the property of others, which may arise out of my involvement in Skydiving, Parachute Jumping and Related Activities, or from my use of the above-mentioned facilities, or equipment, or which may be caused, directly or indirectly, by any persons whomsoever or any cause whatsoever, I know and fully appreciate that skydiving, parachute jumping and related activities expose me to the risk of personal injury and even death. I fully appreciate the dangers, and I voluntarily, expressly, assume these risks.

WAIVER OF ALL CLAIMS

For and in consideration of my being permitted by the hereinbefore defined Released Parties to make one or more jumps and to participate in the hereinbefore defined Skydiving, Parachute Jumping and Related Activities, involving one or more of the hereinbefore defined Released Parties, and the use of the associated facilities and equipment, and for other good and valuable consideration the receipt and sufficiency of which is hereby acknowledged, I, for myself and for my heirs, representatives, assigns, successors, and administrators, hereby expressly release and waive any and all claims for negligence, products liability, strict liability, breach of implied warranties of fitness for use and merchantability, and for any other cause of action whatsoever, (whether in contract or in tort, or otherwise) which I may presently or hereafter have, including, but not limited to any and all claims for negligence, whether passive or active, and including without limitation negligent rescue operations, and products liability, strict liability, breach of implied warranties of fitness for use and merchantability, or incidental or consequential damages, which I may, at any time, have against any or all persons and entities involved in these skydiving, parachute jumping and related activities including, but not limited to the hereinbefore defined released parties. I do this with full understanding that no one can guarantee that the equipment utilized in the skydiving, parachute jumping and related activities will not fail, or that it will perform as intended.

I Agree

COVENANT NOT TO SUE

I agree never to institute any suit or action at law or otherwise against any of the Released Parties, or to assist in the prosecution of any claim for damages or any cause of action which I may have by reason of injury to my person or any property, or my death, arising from the activities covered by this Agreement, including but not limited to Skydiving, Parachute Jumping and Related Activities, whether caused by the negligence and/or fault, either active or passive, of any of the Released Parties, or from any other cause. I further expressly agree that I will never raise any claim against any of the Released Parties for product liability, failure to warn, negligence, breach of warranty, breach of contract, or strict liability, regardless of whether my claims for damages or injuries are alleged to result from the fault or negligence of the Released Parties, or any of them. I further agree that my heirs, executors, administrators, personal representatives and/or anyone else claiming on my behalf, shall not institute any suit or action at law or otherwise against any of the Released Parties, nor shall they initiate or assist in the prosecution of any claim for damages or cause of action which I, my heirs, executors, personal representatives, and/or anyone else claiming on my behalf may have by reason of injury to my person or any property, or my death, arising from Skydiving, Parachute Jumping and Related Activities, whether caused by the negligence and/or fault, either active or passive, of any of the Released Parties, or from any other cause. I hereby so instruct my heirs, executors, administrators, personal representatives, and/or anyone else claiming on my behalf, that should any suit or action at law or otherwise be instituted in violation of this Agreement against any of the Released Parties, I agree that the Released Parties shall be entitled to recover, in addition to any other damages that may be incurred, reasonable attorneys fees and costs incurred in defense of such suit or action, including any appeals therefrom.

LIMITATION AND DISCLAIMER OF WARRANTIES

The Released Parties hereby warrant that to the best of their knowledge and belief, the equipment provided by the Released Parties, and any of them, meet and/or comply with applicable Federal Aviation Administration (FAA) regulations and standards for skydiving, parachute jumping and related activities. This warranty is the only warranty made and is made in lieu of any other warranties, express or implied, including but not limited to warranty of merchantability or fitness for a particular purpose, which released parties specifically disclaim. In accepting this limitation and disclaimer of warranty, I specifically waive any claim or claims I might otherwise have or make for defect in design, manufacture, workmanship, maintenance or any other defect in equipment, and I waive any claim I might otherwise have or make that an alternate design was available and would have been safer or in any way better, or that the design employed failed to comply with industry standards, or of failure to warn or inadequate warning.I have read the above paragraph, acknowledge that I understand it and accept the limitation of warranty.

I Agree

EQUIPMENT ADJUSTMENT

I understand that I will be wearing a separate harness, which may need to be adjusted by the jumpmaster or others involved with my Skydiving, Parachute Jumping and Related Activities. If my jump is a tandem jump, I understand that the jumpmaster and/or tandem master will attach my harness to his/her harness and that this will put my body in close proximity to that of the tandem master. It may be necessary during my Skydiving, Parachute Jumping and Related Activities, that I be touched in ways that would, in other circumstances, be deemed offensive, however, I specifically agree to this physical contact between me and the instructor, and/or coach and/or others involved in my Skydiving, Parachute Jumping and Related Activities.

EQUIPMENT

I agree to exercise due diligence for the operation and/or care for any and all equipment I rent or borrow from Skydive Central New York, LLC and that I will be held financially responsible for damage to and /or loss of rented or borrowed equipment. I agree that I will inspect all equipment I am using for safe operation prior to every jump. I agree that any damage caused by me or my equipment to those around me or the aircraft will be my full responsibility and I will held financially responsible any damage.

I Agree

INDEPENDENT CONTRACTOR

By signing this document, I acknowledge that I have been advised, understand and accept that instructors, coaches, parachute packers, photographers and pilots are independent contractors. As independent contractors, no other entity, including but not limited to those coming under the heading of Released Parties may be held responsible for that independent contractors actions, including but not limited to gross negligence, ordinary negligence and willful and/or wanton misconduct.

WILLFUL AND/OR WANTON CONDUCT OR MISCONDUCT

In the event any agent or claimed agent or independent contractor of the Released Parties is guilty of willful and/or wanton conduct or misconduct, reckless conduct, or any conduct claimed to be or deemed to be outside the scope of this contract, by action or law or for any reason, I agree that the entitys or persons action shall be beyond the scope of his/her/its employment and shall not be attributable to the Released Parties, or any other entity on any agency theory, or on any other theory. This shall also apply to any acts which are alleged to be, or are deemed to be, willful and/or wanton or reckless on the part of any agent, employee, or any person or entity acting, or claimed to be acting, on behalf of, or instead of, any entity included in the definition of Released Parties.

I Agree

INDEMNIFICATION

I hereby agree to indemnify, defend, protect, save and hold harmless the Released Parties, and each of them, from any and all losses claims, actions or proceedings of every kind and character whatsoever by any and all third parties, and/or their property, whether arising in contract or in tort, or otherwise, including but not limited to claims for compensation, incidental, consequential, punitive, and other damages, damages for wrongful death, products liability or negligence or gross negligence, whether passive or active, and including but not limited to negligent rescue, and for attorneys fees, any or all of which may arise directly or indirectly as a result of my breach of any of the covenants of this Agreement, or which may result from the negligence, gross negligence, and/or fault, either active or passive, of any of the organizations and/or persons hereinabove described as Released Parties, including without limitation from negligent rescue operations, or from my own negligence, gross negligence and/or fault, either active or passive. I also hereby agree to indemnify, defend, protect, save and hold harmless the Released Parties, and each of them from any and all claims for damages, fines, demands, and attorneys fees and other damages and/or compensation, which may be made by third parties against any of the Released Parties, resulting from my Skydiving, Parachute Jumping and Related Activities.

ADEQUATE PROVISIONS FOR SURVIVORS

I certify that considering my lifestyle, the ultra hazardous nature of the Skydiving, Parachute Jumping and Related Activities in which I am about to engage, and the manner in which I am supporting my dependents, if any, I have made adequate provisions for my spouse, if any, my heirs, if any, and all other persons dependent upon me so that in the event of my death or injury they will suffer no financial loss for which I have not made adequate provisions.

I Agree

VALIDITY/ENFORCEMENT IN WHOLE AND IN PART

I understand and agree that this document is a legally binding contract. I further agree that should any Court determine that any clause or provision of this contract is illegal or otherwise unenforceable, such determination shall not affect the validity and enforceability of the remaining provisions hereof, all of which shall remain in full force and effect. I further agree that if any portions of this document are found to be against public policy, that only that portion shall fail, but I specifically waive any unenforceability or any public policy argument that I may make, or that may be made on behalf of myself, my estate or by anyone or any entity who or which could or does sue because of my INJURY OR DEATH.

NO INSURANCE COVERAGE

I understand that THE RELEASED PARTIES CARRY NO INSURANCE OF ANY KIND TO COVER ANY LOSS I MAY SUSTAIN. This means that they carry no medical insurance, no property insurance, no wage loss insurance, or any other insurance to cover any loss I may sustain, nor do any of the Released Parties employ a doctor to give medical advice to determine whether or not a past or current injury or condition should prohibit or affect my participation in Skydiving, Parachute Jumping and Related Activities. I understand and agree that I must seek independent medical advice regarding any questions regarding my physical and mental ability to participate in skydiving, parachute jumping and related activities. I further agree for myself and for my heirs, assigns, representatives, successors and administrators that neither I nor any of my heirs, assigns, representatives, successors or administrators will seek reimbursement or indemnification from any released party or released parties or any of them, for any insurance payments of any kind, or for reimbursement for any expenses, including but not limited to medical expenses and funeral and burial expenses, which may be incurred by me in connection with my skydiving, parachute jumping and related activities.

I Agree

CHANGE IN MEDICAL/HEALTH CONDITION

I hereby agree to inform the Released Parties, and each of them, in writing, of any changes in my medical condition status, including but not limited to, any requirement for me to take any drug, prescription or otherwise, or to seek the advice of any medical doctor, chiropractor, or any other health care professional, and I shall not participate further in Skydiving, Parachute Jumping and Related Activities until all of said medical doctors, chiropractors, and other health care professionals have expressly, in writing, determined that I may again participate in said Skydiving, Parachute Jumping and Related Activities.

NON-USE OF ALCOHOL, CONTROLLED SUBSTANCES AND OTHER DRUGS

I hereby state and affirm that I will not use, and have not used, alcohol, controlled substances, or other drugs, prescription or otherwise, within 12 hours prior to or during my skydiving, parachute jumping and related activities.

I Agree

PHOTO/VIDEO RELEASE

I understand and agree that any photos and/or video taken of me at, around and/or above the facilities of Skydive Central New York, LLC, and/or by the Released Parties, or any of them, or by any of their agents or representatives, may be used for promotional and any and all other purposes by Skydive Central New York, LLC as it may see fit to do, without compensation to me, or to anyone claiming on my behalf, and without my further permission I further hereby agree that any copyright for any such photos and/or video taken of me shall lie with Skydive Central New York, LLC, or their assignees, and that none of such photos and/or video shall be considered to be a work for hire. I also consent to the use of my name in conjunction with any use of any such photo or video, without compensation to me, or to anyone claiming on my behalf.

RELEASE AND WAIVER INTERPRETATION

I understand and agree that this Agreement Applies to all phases of my involvement in Skydiving, Parachute Jumping and Related Activities, and I agree that this document shall be broadly construed in favor of any and all of the released parties and against me and that any and all ambiguities shall be resolved in favor of any and all of the Released Parties referred to in this agreement. I am, by reading this paragraph, being made aware that the general rule is that this type of document is to be narrowly construed and ambiguities are to be decided against the person or entity preparing the document. I expressly waive that rule.

I Agree

LEGAL AGE TO CONTRACT

I hereby state that I am of lawful age to enter into this contract (18 YEARS OF AGE OR OLDER) and am legally competent to execute this Agreement and I further understand that the terms contained herein are contractual in nature, and are not mere recitals. I have executed this Agreement of my own free will.

CONTINUATION OF OBLIGATIONS

I hereby agree and acknowledge that all of the terms and conditions of this Agreement and Waiver shall continue in full force and effect now and in the future at all times during which I participate either directly or indirectly in Skydiving, Parachute Jumping and Related Activities and shall be binding upon my heirs, executors, administrators, personal representatives and/or anyone else claiming on my behalf.

I Agree

WAIVER OF JURY TRIAL AND CONSENT TO CHOICE OF LAW AND VENUE

The procedural and substantive law of the State of New York shall apply to any and all issues involving the construction, interpretation and validity of this Agreement, and New York procedural and substantive law shall govern any dispute between the parties hereto arising from the activities covered by this Agreement. All provisions of this Agreement to the contrary notwithstanding, if suit is brought against any of the Released Parties. I hereby expressly waive my right to a jury trial and agree that the State courts of Cayuga County, New York shall be the sole venue for any suit or action arising from the activities covered by this Agreement.

NO MODIFICATION OF AGREEMENT

This Agreement shall not be amended, modified, or altered without the express, written, consent of all of the parties hereto.

I Agree

MERGER OF ANY OTHER PRIOR AGREEMENT

This Agreement contains the entire agreement of the parties hereto with respect to the subject matter herein addressed, and all prior understandings and agreements, whether written or oral, between the parties hereto relating to the subject matter of this Agreement are merged in this Agreement or superseded hereby; provided further, however, that if I have executed, or in the future execute any other agreement or agreements containing provisions relating to the exemption and/or release from liability and/or covenant not to sue in connection with the Skydiving, Parachute Jumping and Related Activities, I agree that the agreement which provides the most protection from liability and/or suit to the Released Parties, and any and each of them, shall be deemed to be controlling.

TITLES AND SUBTITLES

Titles of the sections are placed herein for convenient reference only and shall not to any extent have the effect of modifying, amending, or changing the expressed terms and provisions of this Agreement.

I Agree

REFUND POLICY

I fully understand and agree that all skydiving services including video and picture services are considered services rendered and are non-refundable. In the event the cameras fail Skydive Central New York at its option will refund the cost of the Video and/or Pictures only. A re-jump will not be given. In the event of cancelation due to weather or mechanical issues I fully agree and understand that I will be issued a rain check or gift certificate that will be valid for one year. I also agree that due to the weight and balance of the aircraft, instructor availability and other students I may not be able to jump with my friends and in the event that this does happen there are no refunds.

I Agree

DROP ZONE RULES

  • Do not drive on the airport.
  • The Manifest office is off limits.
  • No double manifesting.
  • No consumption of alcohol is allowed until after the last load of the day has landed.
  • All USPA BSR's and FAR's must be followed without exception.
  • No smoking in buildings or near skydiving equipment and aircraft, please dispose of your butts.
  • This is a DRUG FREE Drop Zone. You will be banned permanently from this drop zone if you use drugs at our DZ.
  • Do not cross the runway under canopy below 500 feet
  • Dogs and/or pets are not permitted.
  • Swooping: If you are capable of a maneuver you are more than welcome to perform it. If you're looking to learn, just ask to get some to get some coaching. Freedom has two sides though, and the flipside of this coin is that no one will help you pretend it is someone else's fault if you get hurt. If you hurt someone else be ready to own up to your responsibilities as an adult.
  • Follow a left hand traffic pattern.
  • Skydiving is an adult activity and the airport is a dangerous place for children; therefore, children under the age of fifteen must be under the direct constant supervision of an adult while at the Airport Facility/Drop Zone. No exceptions!!
  • If you land on the north side of the runway look both ways before crossing. If a plane is on final approach it has the right of way. Kneel down and face the landing plane so the pilot knows you see them.
  • Treat all neighboring landowners and fellow aviators with respect. If you land off the DZ you will probably be landing on somebody's private property. This is considered trespassing and the landowner may not be happy that you are on their property. You would not like to come home to find a stranger on your land no matter where they came from. When the landowner is upset and yelling at you to get off their property, swallow your pride, be NICE, apologize and exit their property quickly. If you cannot handle doing this: DO NOT JUMP HERE!

I am further aware that I should seek competent legal counsel prior to signing this document, and by my signature below, in addition to agreeing to all of the terms, conditions and covenants contained in this document, I have either consulted competent legal counsel prior to signing this document, or I have voluntarily chosen not to do so.

I HAVE CAREFULLY READ THIS ENTIRE WAIVER, RELEASE OF LIABILITY, HOLD HARMLESS AND INDEMNIFICATION AGREEMENT AND COVENANT NOT TO SUE ("AGREEMENT"), FULLY UNDERSTAND IT, AND I AGREE TO BE BOUND BY ITS CONTENTS. I FULLY UNDERSTAND THE POTENTIAL AND THE REAL DANGERS INCIDENTAL TO ENGAGING IN SKYDIVING, PARACHUTE JUMPING AND RELATED ACTIVITIES. I AM AWARE THAT BY SIGNING THIS DOCUMENT, I AM ENTERING INTO A BINDING CONTRACT, AND I AM THEREBY GIVING UP IMPORTANT LEGAL RIGHTS, AND IT IS MY INTENTION TO DO SO. I UNDERSTAND THAT THIS DOCUMENT IS LEGALLY BINDING AND WILL PRECLUDE ME FROM RECOVERING MONETARY AND/OR OTHER DAMAGES FROM THE RELEASED PARTIES, AND ANY OF THEM, AND/OR FROM OTHER INDIVIDUALS AND ENTITIES, WHETHER SPECIFICALLY NAMED OR NOT.

I Agree

July 23, 2018

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
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:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Identification

Picture US or Canadian Drivers License, US Military or Passport are the only acceptable forms of identification.  You must bring your ID with you.


State, Province or Country of issuance *

Identification Number *
USPA

Date of Last Jump. *

USPA # *

USPA License Number *

Total Jumps *

Main Canopy Size *

Wing Loading *
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Statement of Condition of Health

I hereby state and affirm that I am in good physical and mental health.  If I am in doubt about my physical or mental health I will check with my doctor and bring a doctors note before I participate in Skydiving, Parachute Jumping and Related Activities, I further state and affirm that I am not under the care of any doctor, other health care professional or medical facilitys care for, nor do I have any mental or physical condition which might interfere with, prohibit, or detrimentally affect, my participation in Skydiving, Parachute Jumping and Related Activities, except as described below:


List medical conditions. If none leave BLANK.

Height *

Weight *
Do you wear corrective lens? If I am prescribed corrective lens, I agree to wear them during my intentional parachute jump.*
No
Yes
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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