Loading...

Please take a moment to complete our online boat tour waiver prior to your arrival to help expidite the check-in process. Please note! Each participant in your group must complete a separate waiver.

Thank you! We look forward to seeing you soon!

 

TOURS

DILLON MARINA MEDICAL AUTHORIZATION AND LIABILITY RELEASE
THIS IS A RELEASE OF LIABILITY: PLEASE READ CAREFULLY BEFORE SIGNING

I (and in the event that the participant is a minor, the parents or guardians) hereby authorize all persons or entities connected with the Town of Dillon, Inc. including their agents, employees and assigns, to arrange for such medical treatment and hospitalization as may be required by me/my child, including the administration of anesthesia, drugs and surgical services in the event that such care and treatment is necessary because my/my child’s participation in the tours provided by the Town of Dillon, Inc. I also guarantee payment for all services rendered by any physician and/or hospital in the course of such care and treatment.

May be contacted for medical history information if necessary.

I Agree

I (and in the event that the participant is a minor, the parents or guardians) realize and acknowledge that boating has inherent risks and hazards, that I may be subject to serious or fatal injury from this activity, and that no form of pre-planning can eliminate all the dangers that I may expose myself to, including, but not limited to, rough water, natural obstacles, submerged debris, the boat which might capsize, inclement weather and other persons engaged in water-related activities.

I (AND IN THE EVENT THAT THE PARTICIPANT IS A MINOR, THE PARENTS OR GUARDIANS) HEREBY ASSUME ALL RISKS IN CONNECTION WITH THIS ACTIVITY AND DO HEREBY RELEASE THE TOWN OF DILLON, INC. THEIR OWNERS, AGENTS, EMPLOYEES AND ASSIGNS FROM ANY AND ALL THE LIABILITY, NEGLIGENCE OR BREACH OF WARRANTY FOR ANY INJURIES AND/OR DEATH TO MYSELF/MY CHILD OR DAMAGE TO PROPERTY, AND FROM ANY CLAIM BY ME, MY FAMILY, ESTATE, HEIRS, OR ASSIGNS ARISING DIRECTLY OR INDIRECTLY FROM OR IN ANY WAY CONNECTED WITH MY PARTICIPATION IN THIS ACTIVITY.

I HAVE CAREFULLY READ THE FOREGOING RELEASE, UNDERSTAND ITS CONTENTS, AND SIGN IT OF MY OWN FREE WILL WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Today's Date: March 20, 2019

First Participant's Name

First Name*

Last Name*

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

Dr.:

Dr. Phone:
First Participant's Signature*
Second Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Third Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Fourth Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Fifth Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Sixth Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Seventh Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Eighth Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Ninth Participant's Name

First Name*

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

Dr.:

Dr. Phone:
Tenth Participant's Name

First Name*

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

Dr.:

Dr. Phone:
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.
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*

Last Name*

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

Dr.:

Dr. Phone:
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