Loading...

SCUBA SCHOOLS OF AMERICA & SWIM

~ DIVER ~

STUDENT REGISTRATION AND ACTIVITY RELEASE

Date: February 22, 2020

Please select who will be participating...
AdultMinor
Continue
First Divers Name

First Name*

Middle Name

Last Name*

Phone*
First Divers Date of Birth*
First Divers Information

Occupation *
How did you hear about us?*
Have you ever been diving before?*

If yes, Where?

When?
Do you know someone who dives? If not a diver please skip this*

If yes, Who?
Reason for taking swim or scuba classes:*

Do you know anyone who you would like to have dive with you? (Name and Phone):

TUITION FEE AND REFUNDS: Your Tuition Fee is refundable up to the start of your class. 

NO REFUNDS PRIOR TO THE COMPLETION OF THE PROGRAM 

I certify that I do not have, nor do I have a history of the following ailments: Heart Ailments, Sinus, Asthma, Emphysema, Ear or Mastoid Ailments, Epilepsy, Facial Injuries, Tetanus Allergy, Hypertension, Cancer. 

*I hereby release and allow Aquatic Outfitters, LLC, dba Scuba Schools of America and/or its representatives and affiliates to use any photographs, film, drawings, or mechanical recordings of myself or my voice that might be made during my participation in any promotional use they may desire. 

For and in consideration of permitting the above named to enroll in and participate in diving activities and class instruction of skin and/ or scuba diving by a sanctioned member of SSI, the undersigned hereby voluntarily releases, discharges, waives, and relinquishes any and all actions for personal injury, property damage or wrongful death occurring to him/ herself arising as a result of engaging or receiving instructions in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities or instructions may continue, and the Undersigned does for him/ herself, his/ her heirs, executors, administrators and assigns hereby release, waive, discharge and relinquish any action or cause of action, aforesaid, which may hereafter arise for him/ herself and for his/ her estate, and agrees that under no circumstances will he/ she or his/ her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, property damage or wrongful death against SSI or its member school or any of its officers, agents, servants, associates or employees for any of said cause of action, whether the same shall arise from the negligence of any of said persons, or otherwise. 

IT IS THE INTENTION OF THE ABOVE NAMED STUDENT BY HIS INSTRUMENT TO EXEMPT AND RELIEVE Aquatic Outfitters, LLC, SSI, ANDI, SCUBA SCHOOLS OF AMERICA, and SCUBA X TRAVEL, FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE! 

Further, the undersigned Has Read and Accepts the Responsibility of the Scuba Schools of America Posted System Guarantee and had been given a copy of the guarantee. 

THE UNDERSIGNED ACKNOWLEDGES THAT HE/ SHE HAS READ THE FOREGOING PARAGRAPHS, HAS BEEN FULLY AND COMPLETELY ADVISED OF THE POTENTIAL DANGERS INCIDENTAL TO ENGAGING IN THE ACTIVITY AND INSTRUCTING OF SNORKELING, SKIN AND/ OR SCUBA DIVING, AND IS FULLY AWARE OF THE LEGAL CONSEQUENCES OF SIGNING THE WITHIN INSTRUMENT. 

First Divers Signature*
Divers 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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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

Occupation *
How did you hear about us?*
Have you ever been diving before?*

If yes, Where?

When?
Do you know someone who dives? If not a diver please skip this*

If yes, Who?
Reason for taking swim or scuba classes:*

Do you know anyone who you would like to have dive with you? (Name and Phone):

TUITION FEE AND REFUNDS: Your Tuition Fee is refundable up to the start of your class. 

NO REFUNDS PRIOR TO THE COMPLETION OF THE PROGRAM 

I certify that I do not have, nor do I have a history of the following ailments: Heart Ailments, Sinus, Asthma, Emphysema, Ear or Mastoid Ailments, Epilepsy, Facial Injuries, Tetanus Allergy, Hypertension, Cancer. 

*I hereby release and allow Aquatic Outfitters, LLC, dba Scuba Schools of America and/or its representatives and affiliates to use any photographs, film, drawings, or mechanical recordings of myself or my voice that might be made during my participation in any promotional use they may desire. 

For and in consideration of permitting the above named to enroll in and participate in diving activities and class instruction of skin and/ or scuba diving by a sanctioned member of SSI, the undersigned hereby voluntarily releases, discharges, waives, and relinquishes any and all actions for personal injury, property damage or wrongful death occurring to him/ herself arising as a result of engaging or receiving instructions in said activity or any activities incidental thereto wherever or however the same may occur and for whatever period said activities or instructions may continue, and the Undersigned does for him/ herself, his/ her heirs, executors, administrators and assigns hereby release, waive, discharge and relinquish any action or cause of action, aforesaid, which may hereafter arise for him/ herself and for his/ her estate, and agrees that under no circumstances will he/ she or his/ her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, property damage or wrongful death against SSI or its member school or any of its officers, agents, servants, associates or employees for any of said cause of action, whether the same shall arise from the negligence of any of said persons, or otherwise. 

IT IS THE INTENTION OF THE ABOVE NAMED STUDENT BY HIS INSTRUMENT TO EXEMPT AND RELIEVE Aquatic Outfitters, LLC, SSI, ANDI, SCUBA SCHOOLS OF AMERICA, and SCUBA X TRAVEL, FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE! 

Further, the undersigned Has Read and Accepts the Responsibility of the Scuba Schools of America Posted System Guarantee and had been given a copy of the guarantee. 

THE UNDERSIGNED ACKNOWLEDGES THAT HE/ SHE HAS READ THE FOREGOING PARAGRAPHS, HAS BEEN FULLY AND COMPLETELY ADVISED OF THE POTENTIAL DANGERS INCIDENTAL TO ENGAGING IN THE ACTIVITY AND INSTRUCTING OF SNORKELING, SKIN AND/ OR SCUBA DIVING, AND IS FULLY AWARE OF THE LEGAL CONSEQUENCES OF SIGNING THE WITHIN INSTRUMENT. 

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