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Des Moines Skydivers, LLC waiver Revised 03/30/2012.

MEDICAL STATEMENT

I represent and warrant that I have disclosed all infirmities and medications in the Medical Information section (or indicated "none" if not applicable). If I am prescribed corrective lenses, I agree to wear them during my intentional parachute jump.

I Agree

NOTICE: All medical information provided is for the use of the Des Moines Skydivers, LLC in case you are injured. YOU ARE SOLELY RESPONSIBLE for determining whether you are fit to jump. 

I Agree

RELEASE OF LIABILITY AND AGREEMENT

This is an important legal document. Allow yourself suf­ ficient 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 for being permitted to utilize the facilities and equipment owned or arranged by the Des Moines Skydivers, LLC. (hereinafter "DMSD"), I hereby agree as follows:

1.   VOLUNTARY PARTICIPATION. I understand that I am not required to participate in any skydiving-related activi­ties.  I further understand that, to the extent that I choose to participate in skydiving-related activities, I am not required to do so with DMSD.  I know that there are other skydiving operations to which I may go within a 200-mile radius of Des Moines or such other location where this agreement is being signed.  I also know that I am free to change my mind about participat­ing in skydiving-related activities at any time.  I understand that DMSD will fully refund any payments I have made, other than my deposit, should I decide not to engage in skydiving-related activities with DMSD out of concern for my health or safety, out of a desire not to assume the serious risks associated with such activities, or out of a desire not to be bound by this agreement.

I Agree

2.   PARTIES COVERED.  This release ofliability and agreement covers DMSD, its members, managers, employees, affiliated organizations, agents, independent contractors, volunteers, and others providing services or facilities at its request or direction.  Without limiting the foregoing, this release specifically covers skydiving instructors, riggers, parachute packers, pilots, aircraft owners, airport owners or authorities, airport operators, all members of DMSD, the United States Parachute Association, and any of the foregoing persons' or entities' employees, officers, directors, managers, or the like. 

I Agree

3.   RISKS CONTEMPLATED. This release of liability and agreement contemplates all risks of injury, death, property damage, or other damage to myself or others associated with my participation in skydiving-related activities and my presence on or in the vicinity of an airport at which skydiving-related activities are occurring, regardless of whether such risks are un­ foreseen by me or others or whether the particular events causing injury, death, or damage are unexpected or are of an unlikely nature.  Without limiting the foregoing, I understand that such risks may include injury or death caused by the negli­ gence of myself or one or more of the parties covered by this release in any of the following:  instructing or jump-mastering,  putting on equipment, attaching equipment to the aircraft or to a tandem parachute, maintaining equipment, facilities, or aircraft, packing main or reserve parachutes, piloting the aircraft on the ground or in the air, taking me or others on a tandem or solo skydive, operating skydiving equipment, freefalling or operating a parachute alone or near others, landing a parachute with or without guidance, engaging or failing to engage in emergency or rescue efforts, providing or failing to provide infor­ mation or assistance to rescuers, transporting me or others by vehicle, allowing other persons to be present or to engage in any skydiving-related  activities, or allowing animals to be present. I understand that I or others can be seriously injured or killed by any aspect of skydiving, including, but not limited to, aircraft mishaps or crashes, equipment failures, hard para­ chute openings or landings, failure of a parachute to fully open, high-speed impacts with the ground, entanglement or stran­ gulation by lines or bridles, being struck by other skydivers or objects in freefall, under canopy, or while on the ground, or being struck by aircraft or their propellers while in the air or on the ground.  I also understand that I or others can be injured or killed while on, in or in the vicinity of--or as a result of having been on, in, or in the vicinity of-the facilities of DMSD, such as by falling, being hit by persons, objects, or vehicles, being attacked by animals, being injured while riding as a pas­ senger in a vehicle, or being injured as a result of having consumed alcoholic beverages.  It is my intent for this release of liability and agreement to also apply to the covered parties for any and all such peripheral risks. 

I Agree

4.   RELEASE OF LIABILITY AND INDEMNITY.  I hereby release and discharge DMSD and the covered parties from any and all liability, claims, demands, or causes of action I or others may hereafter have for injury, death, property damage, or other damages from any of the contemplated risks, even if caused by the negligence, ordinary or gross, ofDMSD or such covered parties.  This release shall bind my heirs, successors, and assigns.  I further agree to indemnify and hold harmless DMSD and the covered parties from all claims, judgments and costs, including but not limited to reasonable attorney's fees, and to reimburse them for any expenses whatsoever incurred in connection with any claim, action, or lawsuit brought as a result of my participation in skydiving-related activities, whether brought by myself, my estate, or by others, including claims by my spouse, children, family, or persons injured or damaged by me. 

I Agree

5.   PHYSICAL AND MENTAL FITNESS.  I hereby certify that I am physically and mentally fit to participate in sky­ diving-related activities.  I understand that I am solely responsible for making this determination and that the provision of medical information to DMSD on this form or otherwise does not in any way constitute my reliance upon DMSD or the cov­ered parties to make this determination on my behalf. 

I Agree

6.   COMPLETE AGREEMENT.  This document constitutes the complete agreement between myself and DMSD.  No amendments to this agreement shall be of effect unless in writing and signed by me and all the managers of DMSD. 

I Agree

I further expressly acknowledge and agree that this agreement is intended to be as broad and inclusive as is permitted by the law or the province or state in which the parachute jump is made, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I Agree

I have fully read this agreement and fully understand and agree to all the terms contained herein between myself and Des Moines Skydivers, LLC and/or its affiliated organizations, and I have signed it of my own free will. I further agree that no oral representations, statements or inducements apart from the foregoing written agreement have been made. 

November 16, 2019

First Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*

Phone*
First Voluntary Parachute Jumper Date of Birth*
First Voluntary Parachute Jumper Signature*
Second Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Second Voluntary Parachute Jumper Date of Birth*
Third Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Third Voluntary Parachute Jumper Date of Birth*
Fourth Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Fourth Voluntary Parachute Jumper Date of Birth*
Fifth Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Fifth Voluntary Parachute Jumper Date of Birth*
Sixth Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Sixth Voluntary Parachute Jumper Date of Birth*
Seventh Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Seventh Voluntary Parachute Jumper Date of Birth*
Eighth Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Eighth Voluntary Parachute Jumper Date of Birth*
Ninth Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Ninth Voluntary Parachute Jumper Date of Birth*
Tenth Voluntary Parachute Jumper Name

First Name*

Middle Name

Last Name*
Tenth Voluntary Parachute Jumper Date of Birth*
Voluntary Parachute Jumper 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 and news from Des Moines Skydivers via email.
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*
USPA Information

USPA Member #: *

License #: *

Expiration Date: *
Medical Information
Do you have vision (corrected or uncorrected) adequate to obtain a driver's license?*
No
Yes

What is your uncorrected vision?
Do you wear the following?
Glasses
Contacts
None

Please indicate whether you have been diagnosed with, treated for, or experienced each of the following conditions at any time in the past five years.

Cardiac or pulmonary condition or disease*
No
Yes
High or low blood pressure*
No
Yes
Fainting spells, convulsions, or epilepsy*
No
Yes
Hearing loss*
No
Yes
Nervous or mental disorder*
No
Yes
Diabetes*
No
Yes
Kidney or related diseases*
No
Yes
Neck, back, hip, knee, ankle, or foot injury*
No
Yes
Any orthopedic problems*
No
Yes
Alcoholism or drug addiction or dependency*
No
Yes

If you indicated "yes" in response to any of the above, describe the condition in further detail, including its severity, frequency, last occurrence, method and level of control, and impact upon your functioning:

List your current medications and the conditions for which you take them:
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 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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