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SCUBAJAM ASSUMPTION OF RISK AND WAIVER AND RELEASE AGREEMENT FOR VISITOR, SWIMMER, SNORKELER

VALID From 4-7 Sep, 2020

RULES OF LAKE PHOENIX

  • Rock climbing, jumping or diving from the cliffs or rocks into the water is strictly prohibited.
  • The consumption or use of alcoholic beverages (to include beer and wine) or illegal drugs is strictly prohibited.
  • Glass containers are prohibited from the premises of Lake Phoenix.
  • The display or use of firearms and/or fireworks (to include fire crackers and sparklers) is strictly prohibited on the premises.
  • Fishing is not permitted.
  • Please put all trash into dumpster or other refuse container.
  • Dive knives are prohibited from Lake Phoenix.
  • No rock throwing permitted.
  • All children under 12 and any one that is not a strong swimmerare encouraged to wear a life jacket (positive flotation device) when entering the water.
  • Children must always remain under the direct supervision of their parents or guardian.
  • I have read, understand and agree to abide by all the rules, terms and conditions for useof Lake Phoenix here in and found on Lake Phoenix's website and Information / Policy video, required viewing by all.
  • I will ensure my child, understands and will abide by all the rules, terms and conditions for use of Lake Phoenix here in and found on Lake Phoenix's website and video.
  • These rules must be followed and will be enforced for the safety of all patrons who visit Lake Phoenix.

Please report violations to Lake Phoenixs staff immediately.

Lake Phoenix | 1 Quarry Lane, Rawlings VA | 23876 | Phone: (804) 716-2199

First Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*

Phone*
First Visitor/Snorkeler/Swimmer Date of Birth*
First Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
First Visitor/Snorkeler/Swimmer Signature*
Second Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Second Visitor/Snorkeler/Swimmer Date of Birth*
Second Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Third Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Third Visitor/Snorkeler/Swimmer Date of Birth*
Third Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Fourth Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Fourth Visitor/Snorkeler/Swimmer Date of Birth*
Fourth Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Fifth Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Fifth Visitor/Snorkeler/Swimmer Date of Birth*
Fifth Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Sixth Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Sixth Visitor/Snorkeler/Swimmer Date of Birth*
Sixth Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Seventh Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Seventh Visitor/Snorkeler/Swimmer Date of Birth*
Seventh Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Eighth Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Eighth Visitor/Snorkeler/Swimmer Date of Birth*
Eighth Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Ninth Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Ninth Visitor/Snorkeler/Swimmer Date of Birth*
Ninth Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Tenth Visitor/Snorkeler/Swimmer Name

First Name*

Last Name*
Tenth Visitor/Snorkeler/Swimmer Date of Birth*
Tenth Visitor/Snorkeler/Swimmer Information

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
Visitor/Snorkeler/Swimmer 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.
READ CAREFULLY

I, hereby affirm that I am a competent snorkeler and/or swimmer, and aware of the dangers of snorkeling and swimming at Lake Phoenix without a lifeguard.  I know my limitations, and will stay within the boundaries of my limits.

I plan to visit or snorkel and/or swim at Lake Phoenix in Rawlings, Virginia without an assigned diving leader or a lifeguard during the ScubaJam Virginia event.

I understand and agree that the purpose of my and/or my child(ren) snorkeling and/or swimming activities are strictly recreational and that it is not the function of the staff of Lake Phoenix, or any agent employed by Lake Phoenix or ScubaJam Virginia staff and volunteers, to serve as the guardian(s) of my safety.

I agree to furnish my own snorkeling equipment and be responsible for its good operating condition, regardless of where I obtain it. I further agree that prior to each snorkel, I will check my and/or my child(ren)s equipment to ensure proper function, completeness and familiarity, and do not expect my equipment to be inspected by the staff of Lake Phoenix or ScubaJam Virginia staff and volunteers.

I understand the diving leader(s) may provide advice or assistance to me, and I agree to hold harmless Lake Phoenix or any of its agents, staff, or leader(s) for any of their actions in attempting to be of assistance to me. I do not expect Lake Phoenix or ScubaJam Virginia staff and volunteers or their agents to supervise or control my and/or my child(ren) snorkeling and/or swimming activities in any way. BY SIGNING THIS DOCUMENT, I ASSUME ALL RESPONSIBILITY FOR MY ACTIONS, PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH, even if caused by the negligence of Lake Phoenix or ScubaJam Virginia staff and volunteers, their staff or agents.

I understand that snorkeling and swimming are strenuous activities, and that I can exert myself by doing these activities. IF I AND/OR MY CHILD(REN) ARE INJURED IN ANY WAY FROM A HEART ATTACK, PANIC, HYPERVENTILATION, DROWNING OR FROM FALLING, I EXPRESSLY ASSUME ALL RISK OF THESE INJURIES, AND IN SO DOING, I EXEMPT AND RELEASE LAKE PHOENIX, OR ANY OF ITS STAFF OR AGENTS, FROM ALL LIABILITY OR RESPONSIBILITY RESULTING FROM MY PARTICIPATION IN SNORKELING AND/OR SWIMMING ACTIVITIES.

I am aware that Lake Phoenix is considered to be a remote snorkeling and swimming location, and as a result, I understand it can take Emergency Medical Services 25-40 minutes to respond when called. However, it is my decision to snorkel or swim at Lake Phoenix knowing these facts and limitations.

I have read, understand and agree to abide by the Lake Phoenix rules and have watched their INFOFRMATIONAL and POLICY VIDEO as well as polices as may be promulgated by ScubaJam Virginia during my visit, recreational snorkeling and/or swimming activities. My child(ren) will also abide by these and I have briefed them accordingly.

I understand and agree I am participating in these recreational snorkeling and/or swimming activities voluntarily, and I agree to be completely responsible for my own actions and those of my child(ren). I understand there are living creatures which inhabit the lake such as fish, turtles, and an endangered species of the Northern water snake (no fangs and non-poisonous). I have been warned of the danger of fish and animal feeding or harassment because these creatures can bite.

Vehicle operators are responsible for ensuring all individuals regardless of age and activity at Lake Phoenix have completed their waiver and sign in daily.

I consent and agree that any photos, videos or likeness taken or captured by Lake Phoenix staff, their equipment or their agents can be used as Lake Phoenix management or staff requires.  This includes, but is not limited to, website, flyers, posters, news alerts and on-line media.  I understand that Lake Phoenix is the legal copyright owner of any said photos, videos or likenesses and or reproductions of the same.

I hereby declare I am of legal age and am competent to sign this waiver and release agreement, or that my parent or guardian will sign this document on my behalf if I am a minor (ages 0-17).

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.
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. This waver used for minors between 12 and 17 years of age.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

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

Buddy's Name: *
Individual / Group Selection:*

If part of a group my group leader is:
I am attending as a:*
Non-Diving Youth
Non-Diving Adult

If YOU are the group leader please let us know an estimated group attendance. Please list Youth Divers : Adult Divers: Adult Non-Divers: Youth Non-Divers:

If YOU are the group leader please let us know the dive shop that you are working with, if any.

If YOU are the group leader please let us know who your dive pro(s) are.
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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