Loading...

Skydive Little Washington

200 Airport Rd
Washington, NC 27889
(252) 495-1496

 

 

AGREEMENT, RELEASE OF LIABILITY AND ASSUMPTION OF RISK

IN CONSIDERATION of being permitted to utilize the facilities and equipment of SKYDIVE LITTLE WASHINGTON ,LLC
(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 SKYDIVE LITTLE WASHINGTON, LLC; its agents, associated entities, officers, shareholders, partners, employees, pilots, instructors, jumpmasters; the owners of the aircraft and land utilized for "parachuting activities"; the City of Washington NC; the United States Parachute Association and its members; the manufacturers, distributers, and dealers of parachuting equipment; anyone working with or for SKYDIVE LITTLE WASHINGTON, LLC; and anyone involved in my "parachuting activities", hereinafter referred to in this Agreement, Release of Liability and Assumption of Risk as "SKYDIVE LITTLE WASHINGTON".

2. RISKS CONTEMPLATED. This agreement is made in contemplation of "parachuting activities", included but not limited to parachute jumping, ground instruction, flying and related activities, the exit, free fall, time under the canopy, the landing, any rescue operations or attempts by "SKYDIVE LITLE WASHINGTON" whether on, above or off of any facilities used by "SKYDIVE LITTLE WASHINGTON".

3. RELEASE FROM LIABILITY. I hereby release and discharge "SKYDIVE LITTLE WASHINGTON" from any and all liability, claims, demands or causes of action that I may hereafter have for injuries or damages arising out of my participation in "parachuting activities".

4. COVENANT NOT TO SUE. I further agree that I WILL NOT SUE OR MAKE CLAIM against "SKYDIVE LITTLE WASHINGTON" for damages or other losses sustained as a result of my participation in "parachuting activities".

5. INDEMNIFICATION AND HOLD HARMLESS. I also agree to INDEMNIFY AND HOLD "SKYDIVE LITTLE WASHINGTON" HARMLESS from all claims, judgments and costs, including but not limited to attorney's fees, and to reimburse them for any expenses 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 LITTLE WASHINGTON" 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.

7. PARTIES BOUND BY THIS AGREENMENT. It is my understanding and intention that this Agreement, Release of Liability and Assumption of Risk be binding, not only on 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 to and does in fact release "SKYDIVE LITTLE WASHINGTON" from any and all claims or obligations whatsoever arising in any way from my participation in "parachuting activities".

8. LIMITATION OF WARRANTY. "SKYDIVE LITTLE WASHINGTON" hereby warrants that the equipment provided by "SKYDIVE LITTLE WASHINGTON" has been previously used for "parachuting activities". This warranty is the only warranty made and is made in lieu of any other warranties, expressed or implied, including but not limited to warranty or merchantability or fitness for a particular purpose.
I have read the above paragraph, acknowledge that I understand it and accept the limitation of 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 all subsequent jumps or activities in any way associated with " SKYDIVE LITTLE WASHINGTON".

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 fail, but specifically waive any unenforceability or any public policy argument that I may make or that may be made on my 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. 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 this day of July 20, 2018.

 

First Participant's Name

First Name*

Middle Name

Last Name*

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

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

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*
Video/Image Release
I grant Skydive Little Washington, LLC and each of its affiliates and partners the unrestricted, absolute, perpetual, right and license to reproduce, copy, modify, display, distribute, perform, broadcast, transmit, create derivatives from, and otherwise use in perpetuity my likeness, voice, image, quotes, name, and photograph(s), in whole or in part, or distorted in character or form, either alone and in combination with, or as a composite of, other matter,(hereafter "the Works") through out the nation, in any media or embodiment now known or hereafter to become known, including without limitation, television, print, CD-ROM, the internet and on-line media for the purpose of advertising, publicity, trade, or any other lawful purpose whatsoever including, without limitation, to support Skydive Little Washington's business.*
No
Yes
I agree that no use of the Works need be submitted to me for any approval and that I will not hold Skydive Little Washington, or anyone who receives permission from Skydive Little Washington, liable from the use of the Works in accordance with the terms hereof, including what might be deemed to be misrepresentation of me, my character or my person due to distortion, optical illusion or faulty reproduction which may occur.*
No
Yes
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 Information

HEIGHT

WEIGHT

MEDICAL STATEMENT:

I am not aware of, and am not under treatment for, any physical infirmity or chronic ailment or injury of any nature which would affect my ability to train and/or jump safely and have, or have not, as indicated, been treated, previously or currently for the following:

Cardiac or pulmonary condition or disease*
No
Yes
Back injury*
No
Yes
Drug addiction or dependency*
No
Yes
High or low blood pressure*
No
Yes
Alcoholism*
No
Yes
Diabetes*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Kidney or related diseases*
No
Yes

Any orthopedic problems, Describe
Normal Vision*
No
Yes

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 LITTLE WASHINGTON, LLC will be made on the basis of the statements contained above, and such accepted application will become part of the agreement between myself and SKYDIVE LITTLE WASHINGTON, LLC to provide the service.

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.

Agree To This Document



Powered by  Smartwaiver