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PO Box 474
4 Calle Pedro Marquez
Culebra, PR 00775
787-742-0803

RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH DIVING AND RELATED ACTIVITIES

Any photos taken by Culebra Divers are property of Culebra Divers. I understand and agree photos taken could be used on any and all forms of social media including Culebra Divers website.  We do not take photos of individuals.  

I Agree

I do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with Snorkeling, Skin and/or Scuba diving. I fully understand that these risks can lead to severe injury and even loss of life. I understand that diving operations may be conducted at a site that is remote from a recompression chamber and competent medical assistance. Nevertheless, I choose to proceed even in the absence of a recompression chamber and competent medical assistance. Additionally, I understand that there are also risks associated with dive travel, including, but not limited to the possible injury or loss of life as a result of a dive boat accident, as well as travel to and from dive sites. Despite the potential hazards and dangers associated with the activity of diving, I wish to proceed and I freely accept and expressly assume all risk, dangers and hazards that may arise from diving activities which could result in personal injury, loss of life and property damage to me.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT:

In consideration of being allowed to participate in Snorkeling, Skin and/or Scuba Diving activities as well as the use of any of the facilities and the use of the equipment of the below listed releasees, I hereby agree as follows:

1. TO WAIVE AND RELEASE ANY AND ALL CLAIMS based upon negligence, active or passive with the exception of intentional, wanton or willful misconduct that I may have in the future against any of the following named persons or entities (hereafter referred to as Releasees):

(Instructor/s): All Staff & Instructors
(Facility/ies): Culebra Divers

2. To release the releasees, their officers, directors, employees, representatives, agents and volunteers, from liability and responsibility, whatsoever, for any claims or causes of action that I, my estate, heirs executors or assigns may have for personal injury, property damage or wrongful death arising from Snorkeling, Skin and / or Scuba diving activities whether caused by active or passive negligence of the releasees or otherwise with the exception of gross negligence. By executing this document, I agree to hold the releasees harmless for any injury or loss of life which may occur to me during Snorkeling, Skin and/or Scuba diving activities and/or instruction.

3. By entering into this agreement, I am not relying on any oral or written representation or statements made by the releasees, other than what is set  forth in this agreement. I further agree that this Agreement shall be governed by and interpreted in accordance with the laws of the State of California, United States of America.

4. If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

I hereby declare that I am of legal age and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.

Signature Of Participant / Signature Of Parent Or Guardian If Participant Is A Minor, and by their signature they, on my behalf release all claims that both they and I have.


Date: December 6, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
First Participant's Signature*
Second Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Second Participant's Signature*
Third Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Third Participant's Signature*
Fourth Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

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

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
Tenth Participant's Signature*
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 Culebra Divers periodic email newsletter (I can opt out at any time).
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about us?
How did you hear about us?*

Other:
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*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Date of Tour *

Your information will not be shared or used for any marketing purposes:


Certification Level (Open Water, Advanced, etc.) *

Date of Certification *

Certification Number *

Total Number of Dives to Date *

Date of Last Dive *
Dive Accident Insurance*
No
Yes

Insurance Type/Provider
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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