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SJS Trip - Boat - Social Dive Liabilty Form

Form is valid for one calendar year for all trips, charters, and social event with South Jersey Scuba

(Please Read & Initial) 

1. I understand that scuba diving has inherent risks and dangers associated with it including, but not limited to, risks associated with equipment failure, perils of the sea, acts of fellow divers, decompression sickness, embolism, or other hyperbaric injuries and I specifically acknowledge and assume these risks.

2. I acknowledge that I am a certified scuba diver trained in safe diving practices and that I have practiced and maintained my diving skills within the last year.

3. I will immediately stop my dive if I feel uncomfortable with my diving abilities and/or diving conditions are worse than I have been trained for or have experience to handle.

4. If I become distressed on the surface, I will immediately drop my weight belt and agree to do so if instructed.

5. I am competent in self-rescue techniques and in giving aid to my buddy.

6. I will remain with my buddy at all times.

7. I will inspect all of my diving related equipment (whether owned, rented, or borrowed) prior to leaving the dock and will notify an employee of The Dive Shop NJ LLC dba South Jersey Scuba if any of my equipment is not functioning properly. I hereby fully release, indemnify, and hold harmless the Parties Released from any and all liability resulting from a failure of any diving equipment I am using during the trip.

8. I will have a dive computer, submersible pressure gauge, and a buoyancy system having a minimum of 25 pounds of lift and a power inflator hose on all dives.

9. I am aware of the dangers of holding my breath while diving and hereby fully release, indemnify and hold harmless the Parties Released for any illness or injury resulting to me from this practice.

10. I will inflate my buoyancy system any time I am on the surface, even if I only intend to be on the surface for a few moments.

11. I will arrive on board the boat with a minimum of 500psi of breathing gas still remaining in my tank after each dive.

12. I understand I have a duty to exercise complete care for my own safety and the safety of my dive buddy and agree to exercise this care.

13. I acknowledge and covenant that I am physically fit to scuba dive and snorkel and I hereby fully release, indemnify and hold harmless The Dive Shop NJ LLC dba South Jersey Scuba, properties, their officers, agents, heirs, executors, administrators, instructors, servants, employees, and dive boats, either owned or hired (hereinafter the “Parties Released”) from any and all liability resulting from heart problems, lung problems, illnesses or any other medical problems occurring to me while I am diving and/or snorkeling.

14. I understand that while the Parties Released take all reasonable and necessary steps to maintain cleanliness on a daily basis, the Parties Released cannot be held liable if I contract COVID-19 or any other contagious disease and I expressly understand the risk associated with being on a vessel with a group of other people and expressly release the Parties Released from any and all liability associated with COVID-19 or any other contagious disease.

15. I fully understand and am aware that the dive boat has limited medical facilities and that in the event of any illness or injury to me, appropriate medical care must be summoned by radio and that treatment will be delayed until I can be transported to a proper medical care facility.

16. It is my intention by this instrument to fully release, indemnify, and hold harmless the Parties Released from any and all liability to me and my heirs for personal injury, property damage, or wrongful death whether caused by negligence of Parties Released (including any employee or agent of any of the Parties Released) or otherwise, and I assume all risks in connection with snorkeling and scuba diving activities and instruction.

17. I have read the foregoing in its entirety and agree to the terms and conditions set forth above and for the sole consideration of being allowed to board this dive boat and participate in this diving or snorkeling activity, do hereby bind myself, my heirs, executors, administrators, successors, assigns, and personal representatives to all of the terms and conditions set forth herein.

Today's date: May 16, 2021

First Participant's Name

First Name*

Last Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
First Participant's Signature*
Second Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Third Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Fourth Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Fifth Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Sixth Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Seventh Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Eighth Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Ninth Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
Tenth Participant's Name

First Name*

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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
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(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

DIVE HISTORY


Diver Level: (OW/AOW/Etc.)

Total # of Dives:

# of Boat Dives:

# of Dives in past 12 mths:

# of Dives Below 60 Ft:

Diver Insurance Agency (mandatory for all trips):

Diver Insurance Policy #/Expiration Date:

Travel Insurance Agency (highly suggested for trips):

Travel Insurance Policy #/Expiration Date:
Nitrox Certified:*
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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