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Skydive Moab

WARNING!

SKYDIVING, PARACHUTING, AND ITS RELATED ACTIVITIES CAN BE DANGEROUS AND THERE ARE RISKS INVOLVED IN YOUR PARTICIPATION. YOU CAN BE SERIOUSLY INJURED OR KILLED AS A RESULT OF YOUR PARTICIPATION IN SKYDIVING OR ITS RELATED ACTIVITIES

Please note: After viewing the instructional tape and signing this waiver you are electing to make a skydive. Please realize that skydiving is a weather dependent sport and we will try to jump with you as soon as possible.  If you do not get to jump today, you may have to reschedule for another time. You may get a refund at any time before you suit up.

MEDICAL STATEMENT
I hereby certify that I do not suffer from any physical infirmities or chronic illness, which would affect my ability to engage in Parachute Training and Jumping.

I further certify that I am not on any Regular Medication and have not consumed any Alcoholic Beverages or Drugs within the last twelve (12) hours now and before any jumping activity. I also recognize that it is against Federal, State, United States Parachute Association, SKYDIVE MOAB, LLC and SKYDIVE NEW HAMPSHIRE, LLC and Utah Rules and Regulations to ingest either Alcohol or Drugs while engaging in Parachuting Activities and agree to refrain from doing so.

I certify that I am at least eighteen years of age and have shown proof of my age by State ID, driver’s license, or valid passport.

SKYDIVE MOAB, LLC AND SKYDIVE NEW HAMPSHIRE, LLC - Utah Release Form

THE UNDERLYING DOCUMENT IS A "WAIVER", AN "ASSUMPTION OF RISK AGREEMENT" AND A "RELEASE OF LIABILITY".  READ IT CAREFULLY!
SIGNING THIS DOCUMENT DRASTICALLY AFFECTS YOUR LEGAL RIGHTS.
Skydiving is a dangerous sport!
There is no way to eliminate the possibility of serious injury or death.

AGREEMENT AND RELEASE OF LIABILITY
In consideration for being permitted to use the facilities of SKYDIVE MOAB, LLC and SKYDIVE NEW HAMPSHIRE, LLC, and more generally, the facilities and equipment located at the Grand County Canyonlands Field, North Hwy 191, Moab, Utah, and to engage in parachute jumping, ground instruction, flying and all related activities (Hereinafter referred to as "Parachuting Activities"), I hereby agree to the following:

1.    I HEREBY RELEASE AND DISCHARGE SKYDIVE MOAB, LLC, SKYDIVE NEW HAMPSHIRE, LLC, UNITED STATES PARACHUTE ASSOCIATION (USPA) AND MANUFACTURERS, DISTRIBUTORS AND DEALERS OF SKYDIVING EQUIPMENT, RED CLIFFS LODGE, SORREL RIVER RANCH, MOAB AIRPARK, RANDY DAY, JULIE WENTZ, CAVEMAN RANCH, BUREAU OF LAND MANAGEMENT, COLIN FRYER, SKYDIVE ARIZONA, CLINT MACBETH, MICHAEL CARPENTER, THEIR AGENTS, EMPLOYEES, INDEPENDENT CONTRACTORS, INSTRUCTORS, JUMP MASTERS, PARACHUTE PACKERS, PARACHUTE RIGGERS, PILOTS USED FOR THE PARACHUTING ACTIVITIES AS WELL AS THE CANYONLANDS FIELD AIRPORT AND GRAND COUNTY (Hereinafter referred to as the “RELEASED PARTIES"), FROM ANY AND ALL LIABILITY, CLAIMS, DEMANDS AND CAUSES OF ACTION FOR INJURIES AND DAMAGES ARISING FROM MY PARTICIPATION IN PARACHUTING ACTIVITIES, INCLUDING BUT NOT LIMITED TO LOSSES CAUSED BY THE  NEGLIGENCE OF THE RELEASED PARTIES.

2.    I further agree that I WILL NOT SUE OR MAKE A CLAIM against the Released Parties for damages or other losses sustained as a result of my participation in Parachuting Activities.

3.    I also agree to INDEMNIFY AND HOLD THE RELEASED PARTIES HARMLESS from all claims, judgments, and costs, including attorneys' fees, incurred in the connection with any action brought as a result in my participation in Parachuting Activities, including actions based on the negligence of the Released Parties. 

4.    I understand and acknowledge that Parachuting Activities have inherent dangers that no amount of care, caution, instruction or expertise can eliminate. I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISKS OF PERSONAL INJURY OR DEATH SUSTAINED WHILE PARTICIPATING IN PARACHUTING ACTIVITIES WHETHER OR NOT CAUSED BY THE NEGLIGENCE OF THE RELEASED PARTIES

5.    I have been advised and recognize that my Parachuting Activities are NOT COVERED by any personal accident or general liability insurance policy issued to the Released Parties. 

6.    I agree that any action arising out of my Parachuting Activities are filed in the state of Utah.

   ***************************Please Read Carefully*****************************

7.    I realize that I can opt to stop after reading this form and get a full refund. I choose to SKYDIVE and assume the risk.

   SKYDIVE MOAB, LLC AND SKYDIVE NEW HAMPSHIRE, LLC – Utah Release Form

8.      I certify that I have watched the video introduction explaining the risks of making a skydive and parachute jump which has further explained the information contained in these documents.

9.   I do not hold the Released Parties responsible for damage or loss of my property while with SKYDIVE MOAB, LLC and SKYDIVE NEW HAMPSHIRE, LLC and CANYONLANDS AIRFIELD and GRAND COUNTY and, CITY OF MOAB, and BEAURO OF LAND MANAGEMENT,  and STATE OF UTAH SCHOOL AND INSTITUTIONAL TRUST LANDS ADMINISTRATION

10. I hereby grant the Released Parties and their designees my consent to create video and audio recordings of me and to take photographs of me (both in the air and on the ground) (“Recordings”).  I understand that the Recordings may be used for any purpose (including, among others, advertising, promotion and marketing products or services). I grant permission to the Released Parties, their designees, their sponsors, and their successors and assignors to use my appearance, name, voice, and likeness (at their election) in connection with the Recordings and in any and all manner and media throughout the world in perpetuity.  I agree that the Recordings may be combined with other images, text, and graphics, and may be cropped, altered or modified.

Certified Skydivers Only: In addition to the AGREEMENT & RELEASE OF LIABILITY

I will not cross the runway under 2000Ft AGL. If I land on the NorthWest side of the runway, I will walk away from the runway towards the windsock, and wait for a safety vehicle to pick me up. If I violate the FAR (105.23C) regarding runway crossing I agree to leave the airport immediately and I forfeit and registration or associated jump costs. I recognize if I do not comply with these rules I will face repercussions by the FAA

I promise to abide by all United States Parachute Association, Basic Safety Regulations, Federal Aviation Regulations and State and Local laws.

I promise to maintain all parachute equipment by keeping it current, legal and airworthy. [intial]

I HAVE CAREFULLY READ AND INITIALED THIS AGREEMENT & RELEASE OF LIABILITY, AND CERTIFY THAT I FULLY UNDERSTAND IT. I AM SIGNING THIS AGREEMENT & RELEASE OF LIABILITY OF MY OWN FREE WILL.

Today's Date: December 9, 2019

 

First Participant's Name

First Name*

Last Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
First Participant's Signature*
Second Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Third Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Fourth Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Fifth Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Sixth Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Seventh Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Eighth Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Ninth Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
Tenth Participant's Name

First Name*

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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
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*
USPA Membership

USPA member # *

USPA License number

Total number of Jumps
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

Weight:

Height:
Check Boxes IF you ARE under the treatment for any of the following conditions:
Cardiac or Pulmonary Condition Disease
High or Low Blood Pressure
Fainting Spells or Convulsions
Hearing Loss or Impairment
Nervous Disorders
Diabetes
Kidney or Related Diseases
Shortness of Breath
Psychiatric Disorders
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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