Loading...

This is the Medical Clearance and Waiver for Skydive Vancouver Island, please read it carefully.

MEDICAL STATEMENT FOR UNDERGOING PARACHUTE TRAINING AND JUMPING

I hereby certify that I am not aware of and am not under treatment for any physical infirmity or chronic ailment or injury of any nature and that I have normal vision or have corrective lenses, and that I have never been treated for any of the following:

  • EPILEPSY, EVEN IF WELL CONTROLLED BY DRUGS
  • SEVERE DIABETES WHICH IS POORLY CONTROLLED
  • DRUG ADDICTION OR ALCOHOLISM
  • TOTAL DEAFNESS OR EXCEEDINGLY BAD HEARING
  • MARKED OBESITY
  • RECURRENT DISLOCATION OF THE SHOULDER, UNLESS IT HAS BEEN SUCCESSFULLY TREATED SURGICALLY
  • LARGE INGUINAL HERNIA SHOULD BE SURGICALLY CORRECTED PRIOR TO TAKING PARCHUTE TRAINING
  • HAEMOPHILIACS ARE NOT ACCEPTABLE
  • INDIVIDUALS OVER THE AGE OF 40 SHOULD SHOW A NORMAL STRESS ECG
  • SEVERE ASTHMATICS
  • CARDIAC OR PULMONARY CONDITION
  • HIGH OR LOW BLOOD PRESSURE
  • FAINTING SPELLS OR CONVULSIONS
  • NERVOUS DISORDER
  • KIDNEY OR RELATED DISEASES

I hereby certify and warrant that the statements contained above are true and correct to the best of my knowledge and belief. I further certify and understand that acceptance of this application by Skydive Vancouver Island Inc will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between Skydive Vancouver Island Inc and myself to provide this service.


November 22, 2019

SKYDIVE VANCOUVER ISLAND MAJOR WAIVER

AGREEMENT, RELEASE OF LIABILITY AND ASSUMPTION OF RISK

IN CONSIDERATION of being permitted to utilize the facilities and equipment of SKYDIVE VANCOUVER ISLAND INC (and its associated entities), to engage in parachute activities, ground instruction, flying and related activities, hereinafter collectively referred to as parachuting activities, I HEREBY AGREE AS FOLLOWS:

1. PARTIES INCLUDED. I understand that this Agreement, Release of Liability and Assumption of Risk includes R. Gordon Gauvin, SKYDIVE VANCOUVER ISLAND INC, its agents, associated entities, officers, shareholders, partners, employees, pilots, mechanics, instructors, jumpmasters, the owner of the aircraft (also including 1033389 BC Ltd, Ten Barrel Inc. (dba Nomad Air), The Parksville/ Qualicum Beach Aero Club and the Town of Qualicum Beach, its members, owners, pilots and mechanics), and the owner of the land utilized for parachuting activities, the Canadian Sport Parachuting Association and its members, anyone working with or for SKYDIVE VANCOUVER ISLAND INC, and anyone involved in my parachuting activities, hereinafter collectively referred to in this Agreement, Release of Liability and Assumption of Risk as SKYDIVE VANCOUVER ISLAND INC

2. RISKS CONTEMPLATED. This Agreement is made in contemplation of all parachuting activities, included but not limited to parachute jumping, ground instruction, flying and related activities, the exit, freefall, time under canopy, the landing, and any rescue operations or attempts by SKYDIVE VANCOUVER ISLAND INC whether on, above or off the area known as the SKYDIVE VANCOUVER ISLAND INC or any facilities used by SKYDIVE VANCOUVER ISLAND INC

3. RELEASE FROM LIABILITY. I hereby release and discharge SKYDIVE VANCOUVER ISLAND INC from any and all liability, claims, demands, or causes or action that I may hereafter have for injuries or damages arising out of my participation in parachuting activities even if caused by negligence or any other fault of SKYDIVE VANCOUVER ISLAND INC.

4. COVENANT NOT TO SUE. I further agree that I WILL NOT SUE OR MAKE CLAIM against SKYDIVE VANCOUVER ISLAND INC for damages or other losses sustained as a result of my participation in parachuting activities even if caused by negligence or other fault of SKYDIVE VANCOUVER ISLAND INC

5. INDEMNIFICATION AND HOLD HARMLESS. I also agree to INDEMNIFY AND HOLD SKYDIVE VANCOUVER ISLAND INC HARMLESS from all claims, judgments and costs, including but not limited to solicitor costs, and to reimburse them for any expense whatsoever incurred in connection with any action brought as a result of my participation in parachuting activities.

6. ASSUMPTION OF RISK. I understand and acknowledge that parachuting activities are inherently dangerous and I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISK OF DEATH OR PERSONAL INJURY SUSTAINED WHILE PARTICIPATING IN PARACHUTING ACTIVITIES WHETHER OR NOT CAUSED BY THE NEGLIGENCE OR OTHER FAULT OF SKYDIVE VANCOUVER ISLAND INC including but not limited to equipment malfunction from whatever cause, inadequate training, any deficiencies in the landing area, rescue attempts, bad landings, or any other injury I may sustain even if caused by negligence or any fault of SKYDIVE VANCOUVER ISLAND INC

7. PARTIES BOUND BY THIS AGREEMENT. It is my understanding and intention that this Agreement, Release of Liability and Assumption of Risk be binding not only by myself, but on anyone or any entity, including my estate and my heirs, that or who may be able to or does sue because of my injury or death. It is further my understanding and agreement that this Release is intended and does in fact release SKYDIVE VANCOUVER ISLAND INC from any and all claims or obligations whatsoever arising in any way from my participation in parachuting activities, even if caused by negligence or other fault

8. LIMITATION OF WARRANTY. SKYDIVE VANCOUVER ISLAND INC hereby warrants that the equipment provided by SKYDIVE VANCOUVER ISLAND INC has been previously used for parachuting 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 warrant of merchantability or fitness for a particular purpose. I have read the above paragraph, acknowledge that I understood it and accept the limitation of the warranty

9. DURATION OF RELEASE. It is my understanding and intention that this Release and Agreement be effective not only for my first jump but for any subsequent jumps or activities in any way associated with SKYDIVE VANCOUVER ISLAND INC

10. ENFORCEABILITY. I agree that if any portions of this Agreement, Release of Liability and Assumption of Risk are found to be unenforceable or against public policy, that only that portion shall fall, but I specifically waive any unenforceability or any public argument that I may make or that may be made on behalf of my estate or by anyone who would sue because of my injury or death

11. LEGAL RIGHTS. It has been explained to me, and I understand, that by signing this document I am giving up important legal rights and it is my intention to do so

12. I AGREE that any photographs or video taken by SKYDIVE VANCOUVER ISLAND INC remains the property of SKYDIVE VANCOUVER ISLAND INC and may be used for any purpose they deem fit

13. UNDERSTANDING/BINDING OF AGREEMENT. I hereby certify that I have read and understand the contents of this document and I wish to be bound by its terms

DATED AT SKYDIVE VANCOUVER ISLAND INC THIS November 22, 2019

Participant

Please select who will be jumping
AdultMinor
Continue
First Participant's Name

First Name*

Middle Name

Last Name*

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

Particpants Height *

Particpant's Weight *
Are you on any medication*
No
Yes

Please list your medications if you answered yes
Participants Current Age*
Do you wear Corrective Lenses (glasses or contacts)*
No
Yes
First Participant's Signature*
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*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Medical Insurance
Do you have medical insurance that will cover you in the event of an accident?*
No
Yes
Skydiving History
Have you Skydived before*
No
Yes

Canadian Sport Parachute Association Membership Number

Expiry Date
Current Canadian Sport Parachute Association Certificate of Proficiency or International Equivalent
Solo
A CoP or International Equivalent
B CoP or International Equivalent
C Cop or International Equivalent
D CoP or International Equivalent
CSPA Current Ratings Held
Coach 1
Coach 2
Coach 3
Jump Master
Ground Control Instructor
Skydive School Instructor
Progressive Freefall Instructor
Tandem Instructor (Sigma)
Tandem Instructor (Strong)
Skydive School Examiner
Exhibition Jump Rating
Rigger A
Rigger B
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*

Relationship*

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

Particpants Height *

Particpant's Weight *
Are you on any medication*
No
Yes

Please list your medications if you answered yes
Participants Current Age*
Do you wear Corrective Lenses (glasses or contacts)*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver