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NOTICE

You are not required to make a skydive at Capital City Skydiving Inc. There are other skydiving centers in the State of Michigan, and you may consult your telephone company’s yellow pages for further information. However, in the event that you wish to make a skydive here and with Capital City Skydiving Inc., you must sign this waiver and release of liability, and also sign the Uninsured United Parachute Technologies, LLC, Tandem Parachute Jumper Agreement.

Today's Date: December 8, 2022

Uninsured United Parachute Technologies, LLC
TANDEM PARACHUTE JUMPER AGREEMENT

This is an important legal document. Allow yourself sufficient time to carefully read and understand the entire document, because by signing it, you are agreeing to give up certain legal rights.

I Agree

In consideration of the Uninsured United Parachute Technologies, LLC, doing business as UPT Vector, and Capital City Skydiving, hereinafter referred to as "Corporation", allowing me the privilege of utilizing a dual-harness, dual container parachute pack assembly (also known as a "tandem parachute system"), designed, manufactured and/or assembled by the Uninsured United Parachute Technologies, LLC, d/b/a UPT Vector, for the purpose of performing an intentional parachute jump, I agree that: 

I Agree

1) Representations, Warranties, & Assumptions of Risk: I understand that parachute jumping will expose me to the risk of personal injury, property damage and/or death. I understand that the success of my jump is dependent upon the perfect functioning of the airplane from which I intend to jump and the parachute system, and that neither the airplane nor the parachute system can be guaranteed to function perfectly. I understand that the airplane and the parachute system are both subject to mechanical malfunctions as well as operator error. I freely, voluntarily and expressly choose to assume all risks inherent in parachute jumping, including, but not limited to, risks of equipment malfunction and/or failure to function, including those which may result from some defect in design, assembly, and/or manufacture as well as those risks arising from improper an/or negligent operation and/ or use of the equipment, for and in consideration of the thrill of participation in this activity, understanding full well that those risks may include personal injury, property damage, and/or death.

I Agree

2) Exemption and Release from Liability: I exempt and release the following persons and organizations: 

I Agree

(A) The Corporations and their officers, directors, agents, servants, employees, shareholders, and other representatives; 

I Agree

(B) Manufacturers, designers, and suppliers of component equipment incorporated in the dual-harness, dual-container parachute pack assembly to which I will be attached during my intentional parachute jump; 

I Agree

(C) Owners, suppliers, and operators of aircraft from which I am to make my intentional parachute jump; 

I Agree

(D) The owner of the dual-harness, dual-container parachute pack assembly, and any of its components, to which I will be attached during my intentional parachute jump; 

I Agree

(E) The operator ("parachutist in command") of the dualharness, dual-container parachute pack assembly to which I will be attached during my intentional parachute jump; 

I Agree

(F) If I am making my intentional parachute jump at or near a parachuting/skydiving facility, the owners and operators of that facility, as well as their officers, directors, agents, servants, employees, shareholders, and other representatives; 

I Agree

(G) The owners and lessees, if any, of land upon and from which the parachute jumping and related aircraft operations are conducted; and 

I Agree

(H) The Toll-Free Skydiving Network, Inc., Uninsured (800) Skydive Leasing Corp., Uninsured (888) Skydive Leasing Corp., Uninsured (877) Skydive Leasing Corp., 1-800 FREEFALL, and any and all other skydiving referral service business entities, and/or owners of fictitious name entities which I may have used in locating and/or deciding upon a parachuting/skydiving facility or other location at which to perform an intentional parachute jump.

I Agree

(I) Any other person and/or organization which is or may be liable for any loss or injury to me and or my property, or my death, arising out of my participation in any of the activities covered by this Agreement (as defined below); 

I Agree

From any and all liability, claims, demands or actions or causes of action whatsoever arising out of any damage, loss or injury to me or my property, or my death, whether occurring while I am training and/or preparing for my intentional parachute jump, while I am present in aircraft from which the jump is to be made, while I am making my intentional parachute jump, or while I am engaged in related activities (hereafter referred to as activities covered by this Agreement), whether such loss, damage, injury, or death results from the negligence and/or other fault, either active or passive of any of the persons and/or organizations described in paragraphs 2(A)-(I) above, or from any other cause.

I Agree

3) Covenant Not to Sue: I agree never to institute any suit or action at law or otherwise against any of the organizations and/ or persons described in paragraph 2(A) through (I) above, or to initiate or assist in the prosecution of any claim for damages or cause of action which I may have by reason of injury to my person or property, or my death, arising from the activities covered by this Agreement, whether caused by the negligence and/or fault, either active or passive, of any of the organizations and/or persons described in paragraph 2(A) through (I) above, or from any other cause. I further expressly agree that I will never raise any claim against any of the organizations and/or persons described in paragraph 2(A) through (I) above 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 parties released. 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 organizations and/or persons described in paragraph 2(A) through (I) above, nor shall they initiate or assist the prosecution of any claim for damages of cause of action which I, my heirs, executors, administrators, personal representatives, and/or anyone else claiming on my behalf may have by reason of injury to my person or property, or my death arises from the activities covered by this Agreement, whether caused by the negligence an/or fault, either active or passive, of any of the organizations and/or persons described in paragraph 2(A) through (I) above, or from any other cause, I hereby so instruct my heirs, executors, administrators, personal representatives, and/or anyone else claiming on my behalf. Should any suit or action at law or otherwise be instituted in violation of this Agreement against any of the organizations and/or persons described in paragraph 2(A) through (I) above, I agree that such organizations and/or persons shall be entitled to recover, in addition to any other damages which may be incurred, reasonable attorneys' fees and costs incurred in defense of such suit or action, including any appeals therefrom. 

I Agree

4) Indemnity Against Claims: I will indemnify, defend, save and hold harmless the organizations and/or persons described in paragraph 2(A) through (I) above from any and all losses, claims, actions or proceedings of every kind and character, including attorneys' fees and expenses, which may be presented or initiated by any persons and/or organizations and which arise directly or indirectly from my participation in the activities covered by the Agreement, whether resulting from the negligence and/or other fault, either active or passive, or any of the organizations and/or persons described in paragraph 2(A) through (I) above, or from any other cause. 

I Agree

5) Validity of Waiver: I understand that if I institute or anyone on my behalf institutes, any suit or action at law or any claim for damages or cause of action against any of the organizations and/or persons described in paragraph 2(A) through (I) above because of injury to my person or property, or my death, due to the activities covered by this Agreement, this Agreement can and will be used in court, and that such agreements have been upheld in courts in similar circumstances.

I Agree

6) Representations and Warranties as to Medical Condition: I represent and warrant that (a) I have no physical infirmity, except those listed in the medical statement below, which medical statement is incorporated herein by reference, am not under treatment for any other physical infirmity or chronic ailment or injury of any nature, and have never been treated for any other of the following: cardiac or pulmonary conditions or diseases, diabetes, fainting spells or convulsions, nervous disorder, kidney or related diseases, high or low blood pressure; (b) I am not under any medication of any kind at the present time; and (c) I do/do not (strike one) wear corrective lenses. If I am prescribed corrective lenses, I agree to wear them during my intentional parachute jump.

I Agree

7) Waiver of Jury Trial/Applicable Law/Venue/Headings: I agree that the law of the State of Florida shall apply to issues involving the construction, interpretation, and validity of this Agreement, and that Florida law shall govern any dispute between the parties arising from the activities covered by this Agreement. In the event this Agreement is violated and suit is brought against any of the organizations and/or persons described in paragraph 2(A) through (I) above, I waive my right to a jury trial, and agree that Volusia County, Florida shall be the sole venue for any suit or action arising from the activities covered by this Agreement. I agree that the headings and sub-headings used throughout this Agreement are for convenience only and have no significance in the interpretation of the body of this Agreement. 

I Agree

8) Severability/Multiple Waivers: I agree that should one or more provisions in this Agreement be judicially determined to be unenforceable, the remaining provisions shall continue to be binding and enforceable against me. If I have executed any other agreement containing provisions relating to the exemption and/or release from liability and/or covenant not to sue in connection with the activities covered by this Agreement, I agree that the agreement which provides the most protection from liability and/or suit to the Uninsured United Parachute Technologies, LLC, d/b/a UPT Vector shall be enforceable against me by the Uninsured United Parachute Technologies, LLC,. d/b/a UPT Vector. 

I Agree

9) Continuation of Obligations: I agree and acknowledge that the terms and conditions of this Agreement shall continue in force and effect now and in the future at all times during which I participate in the activities covered by this Agreement, and shall be binding upon my heirs, executors, administrators, personal representatives, and/or anyone else claiming on my behalf. This Agreement supersedes and replaces any prior such agreement I have signed. 

I Agree

10) Viewing of Videotape: I have viewed and I warrant that I fully understand the accompanying "Tandem Vector Waiver" video tape. 

I Agree

I freely and voluntarily agree to all of the above by signing this contract on the day of December 8, 2022 at Capital City Skydiving, Fowlerville MI.

*Please read each paragraph carefully. Your initial indicates you understand and agree to all of the information and terms contained therein.


Date: December 8, 2022

 

 

 

AGREEMENT, RELEASE OF LIABILITY, ARBITRATION AGREEMENT AND ASSUMPTION OF RISK

Welcome to Capital City Skydiving Inc. Please complete the form below, read, initial and sign the attached waiver. You must be at least 18 years of age and weigh no more than 250 lbs. to skydive. Please wear comfortable shoes, no sandals, and empty pockets of wallets, phones, keys, etc. Don’t bring anything you don’t want to lose: watches, necklaces, bracelets, etc. Capital City Skydiving is not responsible for lost items. Thanks for choosing Capital City Skydiving.

No smoking near the skydiving gear, aircraft or fuel tanks.
Please be respectful of the airplanes and do not touch them.
Stay away from moving airplanes as they may not see you.
Never touch the propellers, even when the plane is parked and the engine is off.

In consideration of being permitted to utilize the facilities and equipment of Capital City Skydiving Inc. (and its associated entities), to engage in “Parachute Activities”, ground instruction, flying and related activities, hereinafter collectively referred to as “Parachuting Activities” and further defined herein, I hereby agree as follows: 

1. Released Parties. This Agreement, Release of Liability, Assumption of Risk and Arbitration Agreement (hereinafter the “Agreement”), is made in favor of the following parties who are referred in this document as the “Released Parties’:

  • Capital City Skydiving Inc., a Michigan corporation;
  • Aivcon, Inc., a Michigan corporation, their officers;
  • Any of their employees, volunteers, and agents;
  • Any and all concessionaires, instructors, packers, pilots, and/or staff participating in my “Parachuting Activities”, as defined further herein;
  • Strong Enterprises, Uninsured United Parachute Technologies, LLC, any and all parachute and skydiving equipment manufacturers;
  • The United States Parachute Association;
  • The land owners of any property used in any and all ways by any and/or all of the above-mentioned parties;
  • The officers, directors, agents, employees, subcontractors, and servants of all of the above-mentioned parties;
  • The pilots and owners of the aircraft utilized for “Parachuting Activities”;
  • Anyone involved in my “Parachuting Activities” hereafter referred to in this Agreement;
  • All of the above parties are hereby collectively referred to as “Released Parties.”

 

2. Risks Contemplated. I understand and acknowledge that “Parachuting Activities” have inherent dangers and that no amount of care, caution, instruction, or expertise will eliminate the risk of DEATH AND/OR SERIOUS BODILY INJURY AND I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISK OF DEATH OR SERIOUS BODILY INJURY SUSTAINED WHILE PARTICIPATING IN “PARACHUTING ACTIVITES” AS DEFINED HEREIN. THESE RISKS INCLUDE THE RISK OF PASSIVE OR ACTIVE NEGLIGENCE OF THE “RELEASED PARTIES”, blatant, or obvious defects on the drop zone or in the equipment or aircraft used. By way of illustration, and not limitation, these risks include the following, all of which are “Parachuting Activities”:

  • Parachute jumping
    I Agree
     
  • Tandem or experimental test parachute jumping
    I Agree
     
  • Ground instruction
    I Agree
     
  • Flying activities
    I Agree
     
  • Exiting from the aircraft
    I Agree
  • Skydiving
    I Agree
     
  • Freefall
    I Agree
     
  • Canopy opening
    I Agree
  • Time under canopy
    I Agree
     
  • The landing - including, but not limited to crash landings, either under canopy or not, inside or outside of the aircraft
    I Agree
     
  • Equipment malfunctions of any kind
    I Agree
     
  • Any rescue operations or attempts, whether on designated landing areas or any facilities utilized by the “Released Parties”
    I Agree
     
  • Ground transportation
    I Agree
     
  • Any activity in any way, shape, or manner connected with my “Parachuting Activities”
    I Agree
     

3. Release from Liability. I hereby release and discharge the above “Released Parties” from any and all liabilities, claims, demands, or causes of action that I may hereafter have for injuries or damages arising out of my participation in “Parachuting Activities” even if caused by negligence or other fault of the above “Released Parties.”

 

4. Covenant not to Sue. I further agree that I will not sue or make claim against the above “Released Parties” for damages or other losses sustained as a result of my participation in “Parachuting Activities” even if caused by negligence or other fault of the above “Released Parties.”

 

5. Defense of “Released Parties” Indemnification and Hold Harmless. I also agree to defend, indemnify and hold the above “Released Parties” harmless from any and all claims, judgments and costs, including, but not limited to actual attorney 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.” I further agree that as part of my obligation to defend indemnify and hold the above “Released Parties” harmless from all claims, judgments, and costs, I agree to post a bond in the amount of $25,000.00 in favor of the above “Released Parties” BEFORE filing any claim or suit against the “Released Parties.”

 

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 4 personal injury sustained while participating in “Parachuting Activities” whether or not caused by the negligence or other fault of the above “Released Parties,” including, but not limited to the risks as set forth in subparagraph 2 above, even if caused by negligence or any fault of the above “Released Parties.”

 

7. Agreement Not Limited to Foreseeable Risk. This release is intended to include all risks associated with my “Parachuting Activities”, including, but not limited to the risk involved in riding in the aircraft. This release is intended to include risk of injury that I do not foresee at this time. This Agreement is intended to include risk of injury that I do not foresee at this time. This Agreement is intended to include all acts and conduct on the part of the “Released Parties,” whether at this drop zone/facility or elsewhere.

 

8. No Insurance Coverage. I have been advised and recognize that “Parachuting Activities” are not covered by any personal accident or general liability insurance policy issued to the “Released Parties.”

 

9. Parties Bound by this Agreement. It is my understanding and intent that this Agreement is 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 Agreement is intended to and does in fact release the above “Released Parties” from any and all claims or obligation whatsoever arising in any way from my participation in “Parachuting Activities,” even if caused by the negligence or other fault of the above “Released Parties.”

 

10. Limitation of Warranty. The “Released Parties” hereby warrant that any equipment provided by “Released Parties” 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 warranty of merchantability or fitness for a particular purpose. “Parachuting Activities” are dangerous and associated equipment such as parachutes do not always work in the way that they are expected to work. Furthermore, I understand that my stability and body position may drastically affect the operation of the equipment. I understand that the parachutes provided by the “Released Parties” have been packed by human beings, and as such, may be subject to a hidden defect in the packing. I understand these disclaimers and I accept this limitation of warranty.

 

11. Duration of Release. It is my understanding and intention that this Agreement be effective not only for my first jump, but for any subsequent jumps or activities which are in any way associated with the above “Released Parties.”

 

12. Enforceability. I agree that if any portion of this Agreement is found to be unenforceable or against public policy, only that portion shall fail and all remaining portions of 5 the Agreement shall remain in full force and effect. I specifically waive any unenforceability or any policy 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.

 

13. Legal Rights. I have read the Agreement, and I understand, that by signing this document I am giving up important legal rights and it is my intention to do so.

 

14. Waiver of Duty. I hereby agree to waive all duty of care, whether by omission or commission, or any other duty that may be owed to me by the “Released Parties.”

 

15. Interpretation of Release. It is my agreement with the above “Released Parties” and my intention that this document be broadly construed in favor of the above “Released Parties” and against me and that any and all ambiguities be resolved in favor of the above “Released Parties.”

 

16. Choice of Laws, Jurisdiction and Venue. I agree that this Agreement shall be interpreted under the laws of the State of Michigan, no matter where I reside or where I execute this Agreement and participate in “Parachuting Activities” with the “Released Parties.” Venue for any disputes or claims arising under this Agreement lies EXCLUSIVELY in the Circuit Court for the County of Charlevoix, State of Michigan.

 

17. Right to use Name and/or Likeness in Advertising. I further acknowledge and agree that during the course of my participation in “Parachuting Activities,” the “Released Parties” may videotape or photograph me. I expressly agree to the use of my name, photograph, or any video footage involving me for advertising purposes, and release the “Released Parties” for any and all liability thereof.

 

18. Independent Contractors. I understand that all jumpmasters, instructors, videographers, parachute riggers, and packers or any other entity or individual which may have participated in any aspect of my skydiving experience with Capital City Skydiving Inc. are independent contractors. I understand that I am personally selecting, hiring, and separately paying them for any service rendered. I understand that all contractor fees were included in the advertised estimated cost and are not additional payments. I further understand that I may provide my own qualified United States Parachute Association rated, trained, and licensed contractor, provided they meet or exceed Capital City Skydiving Inc.’s own minimum experience, currency, and safety standards.

 

19. Provisions for Support of Dependents. I certify that considering my lifestyle and the manner in which I am supporting my dependents, if any, I have made adequate provisions for my spouse, my children, my heirs, and all other persons dependent upon me that 6 in the event of my death and/or disability, they will have suffered no financial loss. I further intend that this Agreement, Release of Liability, Arbitration Agreement, and Assumption of Risk shall be binding upon any and all of my family, heirs, and assigns.

 

20. Agreement to Arbitrate. I further agree that in the event I make any claim against the “Released Parties” and arising out of my “Parachuting Activities,” including an action for personal injury, that it shall be a condition preceding to the filing of any action against the “Released Parties” that I must first submit any dispute arising out of this Agreement to binding Arbitration pursuant to the laws of the State of Michigan, and subject to the jurisdiction and venue provisions as set forth in paragraph 16. The arbitrator shall apply the law in the State of Michigan in reaching an arbitration decision or award, and that arbitrator’s decision shall be final and binding upon all persons and may, if necessary, be made into a judgment as set forth herein.

 

21. Physical Conditions. I hereby certify that I do not suffer from any physical infirmity or chronic illness which would affect my ability to engage in parachute training and all related “Parachuting Activities”, as set forth in the medical statement I will complete at the end of this document. I further certify that I am not on any regular medication and have not consumed any alcohol beverages or drugs within the previous twelve (12) hours. I also recognize that it is against Federal, State, the United States Parachute Association, and Capital City Skydiving Inc.’s Rules & Regulations to consume either alcoholic beverages or illegal drugs while engaging in “Parachuting Activities” and I agree to refrain from doing so.

 

22. Acknowledgment and Merger. I acknowledge and agree that this Agreement contains the entire Agreement between myself and the “Released Parties” as to the matters set forth herein and replaces any and all other prior negotiations, Agreements, whether written or oral between myself and the “Released Parties.” I am executing this Agreement and Release of Liability, this Agreement on my own free will.

 

23. Understanding 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. 

 

Date: December 8, 2022

First Participant's Name

First Name*

Last Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

First Participant's Signature*
Second Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Third Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Fourth Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Fifth Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Sixth Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Seventh Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Eighth Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Ninth Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Tenth Participant's Name

First Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

Parent or Guardian's Email Address

Email*

Confirm Email*
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Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Upload your Goverment Issued photo ID/Driver license or Passport
  
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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*

Last Name*

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

Height: *

Weight: *

Emergency Contact Name: 


Name: *

Phone #: *

Relationship: *

Medical Statement

I am not aware of, nor under treatment for, any physical infirmity or chronic ailment or injury of any nature which would or could affect my ability to skydive or parachute safely; and have, or have not, as indicated below, been treated for the following:

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells or convulsions or epilepsy*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related disease*
No
Yes
Back Injury*
No
Yes
Alcoholism*
No
Yes
Drug addiction or dependency*
No
Yes
Any orthopedic problems, describe:*
No
Yes
Other:*
No
Yes

If Any Orthopedic or Other, please describe:

I hereby certify and warrant that the statements made above are true and correct to the best of my knowledge and belief. I further acknowledge and understand that the acceptance of this application by Capital City Skydiving Inc. will be made on the basis of the statements made above, and such accepted application will become part of the attached Release of Liability/Assumption of Risk/Indemnity Agreement between Capital City Skydiving Inc. and myself. 

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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