Your privacy is critically important to us. Skydive the Ranch has the following fundamental principles:

  • We don’t ask you for personal information unless we truly need it.
  • We don’t share your personal information with anyone except to comply with the law or to protect our rights.
  • We don’t store personal information on our machines or in printed form.

Skydive the Ranch will handle all your personal information in strict compliance with the POPI Act, and only use it for the purposes for which it was supplied to us. For the purpose of this clause, “personal information” shall be defined as detailed in the Protection of Personal Information motion of Access to Information Act 04 of 2013 (POPIA). The POPIA may be downloaded from: http://www.polity.org.za/attachment.php?aa_id=3569

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THIS DOCUMENT IS LEGALLY BINDING VOLUNTEER SKYDIVER / VOLUNTEER PARACHUTIST/ PARTICIPANT / SPECTATOR / TEAM / STAFF MEMBERSHIP APPLICATION, MEDICAL QUESTIONNAIRE, DECLARATION, INDEMNITY, WAIVER AND RELEASE FORM, EXCLUSION OF LIABILITY AND VOLUNTARY ASSUMPTION OF RISK AGREEMENT

Skydive the Ranch is a members only recreational sports skydiving Club affiliated to the Parachute Association of SouthAfrica (PASA) - CAA / ARO 0004. Skydiving and Parachuting operations are conducted in accordance with the PASA Manual of Procedures (MOPs) and part 105of the South African Civil Aviation (CAA) Regulation, and as per terms and conditions laid down by Skydive the Ranch. Skydiving and parachuting are considered extreme sports and high-risk activities.

You must participate voluntarily and accept the risks in exchange for the enjoyment the activity offers.

Participation, and even spectating, is entirely at your own risk.

Pay attention to briefings and / or instructions given.

Skydive the Ranch reserves the right to deny participation to any individual, for any reason, at our sole and unfettereddiscretion. Anyone who is, or appears to be, under the influence of alcohol, drugs or ill health will be refused permission to skydive in the sole and unfettered discretion of Skydive the Ranch.

All clients doing business with Skydive the Ranch will be deemed to have read and accepted to be bound by the contents of this agreement and our Terms and Conditions.

Tandem Skydiving:

Participants young or old, small, or large, must be able to fit into a tandem harness safely and securely.

All participants must be sober, willing, and participate voluntarily.

Age Restrictions: Minimum Age= 12 years, minimum height= 1.2m, minimum weight= 35kg. Anyone under the age of 16 will be cleared by a certified Tandem Evaluator based on these criteria. Any person under the age of 18 requires written parental consent.

Maximum weight is 100 kgs (heavier persons may be considered).

There is no maximum age (elderly persons may require special consideration).

Other restrictions: Not suitable for pregnant women.

Persons with physical or psychological, chronic illness or disabilities will be assessed and may be considered but may refused permission to skydive in the sole and unfettered discretion of Skydive the Ranch.

VOLUNTEER SKYDIVER / VOLUNTEER PARACHUTIST PARTICIPANT / SPECTATOR / TEAM / STAFF DECLARATION, INDEMNITY, WAIVER AND RELEASE FORM, EXCLUSION OF LIABILITY AND VOLUNTARY ASSUMPTION OF RISK AGREEMENT THIS DOCUMENT IS LEGALLY BINDING

Acting on my own volition, of my free and absolute will and without any wrongful and/or undue influence or compulsion from any person whatsoever I confirm that I know and understand that skydiving, parachuting and all aspects of aviation associated with these activities present inherent risks of permanent and other injuries, disfigurement, or even death and that I fully understand the scope, nature, and extent of the inherent risks aforesaid.

I warrant that I have perused the literature presented by Skydive the Ranch, visited their website(s) and have been briefed in detail about and am aware of and accept that I will be exposed to a variety of risks and dangers en route to/on my return from my home/residence and during the activities described herein and to risks and dangers inherent in or associated directly or indirectly with the activities described herein and surrounds, the fact, nature and potential effect of which has been explained to me in detail and that I have had adequate opportunity in the circumstances to receive and comprehend the risk and the implications thereof including obtaining independent advice. I have no misapprehensions and any questions I may have; I have asked and these have been addressed and explained to my satisfaction.

I further covenant and agree hereby that based on my full awareness, knowledge and having been briefed as aforesaid, I by my signature of this INDEMNITY, WAIVER AND RELEASE FORM EXCLUSION OF LIABILITY, and VOLUNTARY ASSUMPTION OF RISK AGREEMENT (hereinafter referred to as ‘the Agreement’), hereby waive any rights and any claims whatsoever I or my dependents, beneficiaries, heirs, executors, administrators may have, could have, or could obtain against any individual, staff, group, member, party, or any associates, agents, subsidiaries, booking offices, ticket issuers, airport owners or operators, aircraft owners or operators, land owners, promoters, advertisers, supporters, staff, management, well- wishers or any other person, group or company and, without limiting the generality of the foregoing Skydive The Ranch, Farm Dwarsfontein, Delmas 2210 (all members, all directors and all employees thereof) howsoever described and / or identified who may have either directly or indirectly either knowingly or without conscious knowledge in the past or in the future contributed or played any role whatsoever either directly or indirectly in my decision to participate in skydiving and parachuting and related activities, or in any activities which were managed or controlled either wholly or in part by Skydive The Ranch or any other individual, party, operation, group, association or organisation, guides and agents of the aforesaid relating either to skydiving and parachuting or to any related aviation activity in any aircraft, in freefall or on the ground in the air or in any building or structure related to the activities which Skydive the Ranch operates from, in, at or under, from time to time either as repeat activities or a once off activity (hereafter collectively referred to as “the Indemnified Parties”) arising directly or indirectly from any losses or damage which I may suffer; including any financial loss and/or destruction and/or loss of property, illness, injury, harm (as defined in section 61 of the Consumer Protection Act, Act 68 of 2008 (‘the CPA’), trauma or death pain and suffering, whether as result of injuries or otherwise (including any medical assistance or treatment), arising from the inherent risks stated above and/or participation in any one or more of the activities above stated or arising from any act and/or omission by the Indemnified Parties including any negligent acts and/or omissions (unless section 61 the CPA is applicable’) and I hereby indemnify and hold the Indemnified Parties harmless and free, released and discharged of any legal liability including any legal costs that may be incurred by the Indemnified Parties on an attorney and own client scale. I agree to always obey, whether in the area of or participating in any activity, any warning notices and/or instructions of the Skydive the Ranch Club management and/or the person in charge of any activity.

I agree to always obey, whether in the area of or participating in any activity, any warning notices and/or instructions of the Skydive the Ranch Club management and/or the person in charge of any activity.

I also acknowledge that the Skydive the Ranch Club management and/or any person in charge of any activity may, in his/her sole discretion, decide to cancel, terminate, or curtail any activity at any stage for whatever reason the person in charge of the activity in his/her sole discretion deems fit if circumstances arise and/or prevail that justify such cancellation, termination or curtailment & I agree to comply accordingly.

I further agree and covenant that the Agreement will not be affected by any failure by the Indemnified Parties to impose any or sufficient procedures or restrictions or to ensure that any or all my undertakings and/or promises herein are adhered to either timeously or at all.

By signing below, I stipulate, record, agree, promise and covenant further that:

I have read all the above provisions, fully understand my agreements, promises, undertakings and covenants therein expressed and have freely accepted the provisions of the foregoing paragraphs relating to assumption of risk, exemption from liability, covenant not to sue, indemnity against and waiver of claims, payment of costs and legal fees and continuation of obligations.

The Indemnified Parties have afforded me an opportunity to take the Agreement to my legal or other advisor before I signed the same and I have by my signature aforesaid waived such right, or alternatively so consulted in which event I agree and covenant hereby never to raise any claim and/or defence that I did not fully understand the terms hereof in the future. I in this event confirm that I understand that the main import, meaning and intention of the Indemnified Parties in seeking my signature hereof is to absolve themselves of any possible liability towards me to the greatest extent permissible at law.

I agree and covenant that in the event that any term of the Agreement is held to be invalid or unenforceable by any court or other tribunal or body of competent jurisdiction such holding shall not invalidate or render unenforceable any other term of the Agreement and I agree in that event, to participate in good faith and to cooperate fully with the Indemnified Parties so that we may use our best endeavours to agree on a suitable substituted arrangement which will be valid and will give effect to the intentions of the parties as reflected in the invalid provisions to the greatest possible extent.

In all instances South African law and jurisdiction applies.

DECLARATION

I. I the undersigned, do hereby certify and warrant that all details provided are true and correct to the best of my knowledge, and that the Agreement is legally binding and has been completed fully and completely and signed of my own free will.

II. I / we have carefully read, fully understood, acknowledge accept to be bound by Skydive the Ranch's Terms and Conditions contained in this Agreement, and accept the terms and conditions upon which I voluntarily undertake to participate - fully understanding there is risk of illness, harm, injury and / or death, and with the knowledge and understanding that I participate entirely at my own risk.

III. I am over 18 years of age / I will ensure that the Agreement is counter signed by my Parent or Legal Guardian providing full legal consent for myself to participate in skydiving and parachuting activities and all related aviation elements as described above.

IV. I weigh less than 100 (One Hundred) kgs / I will ensure that I discus the fact I am over 100 (One Hundred) kgs with the Chief Instructor /Tandem Instructor / Skydiving Instructor prior to participation in skydiving and parachuting activities and related aviation elements.

V. I do not suffer from any physical, psychological, or chronic illness or disability / I will ensure that I discuss any physical, psychological or chronic illness or disability that I may suffer from, including and medical treatment I may be receiving or medication (whether prescribed ornot) I am taking / using with the Chief Instructor / Tandem Instructor / Skydiving Instructor prior to engaging in skydiving and parachuting activities and related aviation elements.

VI. I am not on any medication, drugs or undergoing any course of treatment, nor influenced by alcohol that could affect my ability to engage in skydiving and parachuting activities and related aviation elements / I will ensure that I discuss any medication, drugs or course of treatment, or the fact that I may be under the influence of alcohol or drugs that could affect my ability engage in skydiving and parachuting activities andrelated aviation elements with the Chief Instructor / Tandem Instructor / Skydiving Instructor.

VII. I acknowledge and accept that participation in skydiving and parachuting activities and related aviation elements involves an element of risk.I assume and accept responsibility for myself and decisions regarding my safety and participate in skydiving and parachuting related activities and all aviation related elements voluntarily and entirely at my own risk.

VIII. I will ensure that I receive and understand briefings and instructions given to me by the Chief Instructor / Tandem Instructor / Skydiving Instructor and agree however that my failure to so receive and / or to understand and / or to adhere to briefings and / or instructions will notserve to amend, change or in any way absolve me of my undertakings in the Agreement.

IX. I acknowledge and accept that it is my personal choice should I decide to participate in skydiving and parachuting related activities and aviation related elements without adequate and appropriate medical cover / it is my personal responsibility to ensure that I have adequateand appropriate medical cover when participating in skydiving and parachuting related activities and aviation related elements.

X. I agree, for myself my heirs executors and successors to INDEMNIFY, exempt, release, and to FOREVER HOLD HARMLESS all parties, individuals, organisations, associations, clubs, associated companies, personnel, agents and representatives from any and all liability againstall claims, costs, damages, liabilities, demands or actions of any kind whatsoever (which includes acts or omissions whether due to negligence or otherwise), in respect of, or arising out any physical or mental injury or damage of any degree or nature whatsoever or howsoever caused for anyone whomsoever resulting directly or indirectly from my voluntary participation in skydiving and parachuting.

I give permission for video and photographic material featuring myself to be utilised for the purposes of marketing and promoting Skydivethe Ranch, and for the marketing and promoting of Skydiving and Parachuting generally.

I Agree

I give permission for Skydive the Ranch to use my email address to further communicate with me regarding skydiving and parachuting andother related activities.

I Agree

I am authorised to affect the booking and the conditions thereto.

I Agree

Today's date: November 30, 2021

First Participant's Name

First Name*

Last Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
First Participant's Signature*
Second Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Third Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Fourth Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Fifth Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Sixth Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Seventh Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Eighth Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Ninth Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
Tenth Participant's Name

First Name*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
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 Relation to Participant *

Emergency Contact's Phone Number *
Sport Skydivers Only

PASA / FAI Number:

Licence Number:

Current Ratings held with Number:

Main Canopy Make and Size

Reserve Repack date on own gear

Time in Sport (Years)

Total number of jumps

Number of jumps in last 3 months
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*

Relationship*

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

Participant's ID Number *

Height:

Weight: *

Medical Aid Details


Medical Aid Provider: *

Policy Number: *

Medical Aid Emergency contact number

Medical Questionnaire

Do you suffer from, or are you being treated for (tick the appropriate box)
Epilepsy
Diabetes
Heart Condition
Blackouts or dizzy spells
High Blood pressure
Low Blood Pressure
Asthma
Ear Problems/ Infections
Glasses/ Corrective lenses
Single eye/ Limited vision

Other:
Previous Fractures or dislocations:
Legs
Ankles
Neck
Back
Wrists
Shoulders

Briefly describe any boxes checked above:

Other:
Are you pregnant?
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

Briefly describe:
Are you on any Medication?

If yes, please supply details:
Are you currently addicted to or being treated for an addiction to alcohol or other habit forming drugs?

If yes, please supply details:

Blood Group:

Known Allergies:

Do you have any other medical condition, injury, or anything else we should be aware of that we have not mentioned?
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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