Loading...

Sam's Tours 

REGISTRATION FORM

LIABILITY WAIVER - RELEASE

AND

INDEMNIFICATION AGREEMENT 

"DIVING"

Palau Sea Ventures, Inc. dba Sam’s Tours is a licensed business that includes but may not be limited to Planet Blue Sea Kayak Tours, Palau Yacht Support, Unique Dive Expeditions, Sam’s Marina, Sam’s Logo Pro Shop, and Bottom Time Bar & Grill.

I, the undersigned,

SCUBA DIVERS ONLY

Hereby certify that I hold an internationally recognized scuba diving certification card issued by the training agency, that I am aware of the inherent hazards of skin diving and scuba diving, and that I am qualified by the above named training agency to dive using scuba. I am familiar with standard, safe diving practices, including that the use of some prescription drugs, illegal drugs or alcohol is a contraindication to safe diving, and I understand that specific dive planning, dive safety parameters, checking of equipment, and my actual dive operations and profile are my sole and total responsibility. I further understand that as a trained and certified diver, I am at all times responsible for my own personal safety while diving, including assembly, preparation, pre-dive testing and proper use of all diving equipment whether personally owned or rented from Palau Sea Ventures, Inc. dba Sam’s Tours. I understand that I am responsible for monitoring my own air-supply, monitoring my own diving depth and ascending slowly to the surface in accordance with standard safe diving practices. I agree to observe standard safe diving practices at all times and to dive only within the limits of my training, certification, experience and personal comfort levels. I further understand that dive site information provided by Palau Sea Ventures, Inc. dba Sam’s Tours personnel and its contracted affiliates is informational only, and is based upon what the ordinary, prudent, safe diver would recommend. I understand that ocean scuba or skin diving, are physically strenuous activities and that I may be exerting myself while on this diving trip or tour and warrant that I am physically fit to engage in diving. I further understand that scuba diving involves certain risks including decompression sickness, embolism, or other hyperbaric injuries that may require treatment in a recompression chamber.

I understand that I am under no obligation whatsoever at any time to participate in any particular dive and will dive only of my own free will and in accordance with my training, certification, experience and or personal comfort levels.

SCUBA DIVERS & ALL OTHER TOUR PARTICIPANTS

I understand and warrant that I am physically fit to engage in activities that may be physically strenuous and that I may be exerting myself while on a tour. I fully understand that a dive or tour vessel or vehicle is limited in its rescue and emergency medical response capabilities, and that the Palau dive or tour site may be in a remote location distant from any medical and /or recompression facility. As a result, in the event of illness or diving injury, rescue and/or appropriate medical assistance may be significantly delayed and I could sustain further serious injury, including death, from this delay. Knowing the aforementioned, I am prepared to assume such risks.

In further consideration of participating in a Palau Sea Ventures, Inc. dba Sam’s Tours DIVE TOUR, SCUBA COURSE, KAYAK TOUR, SNORKEL TOUR, HIKING TOUR, ROCK ISLAND TOUR or LAND TOUR or any other tours provided by or through Palau Sea Ventures Inc, I hereby unconditionally release Palau Sea Ventures, Inc. dba Sam’s Tours, its agents, employees, officers and directors from any liability, personal injury and property damage resulting from scuba diving, skin diving, snorkeling, swimming, kayaking, fishing, hiking or other such touring activities while participating in and or on board any vessel or vehicle (including kayak) during conduct of such diving or tour operations with or through Palau Sea Ventures, Inc. dba Sam’s Tours.

I do further agree to waive all claims against Palau Sea Ventures, Inc. dba Sam’s Tours, its agents, employees, officers and directors from any expenses, losses or damages incurred as a result of claims or demands hereafter made by me, my estate, heirs or assigns and further agree to institute no action or suit at law or in equity against Palau Sea Ventures, Inc. dba Sam’s Tours, its agents, employees, officers and directors, or in any way aid in the institution or prosecution of any claims, demand, action or cause of action, for damages, costs, loss of services, expenses or compensation for or on account of any damage, loss by injury either to myself, property (including scuba equipment, cameras, video or housing equipment), or both, whether known or unknown, past present, or future, arising out of any personal injury or property damage incurred by me while aboard any vessel or vehicle owned, leased, chartered, rented or in any way operated by Palau Sea Ventures, Inc. dba Sam’s Tours, or while using said vessels or vehicles for any purpose related to Palau Sea Ventures, Inc. dba Sam’s Tours.

I have read the foregoing document, understand it, and execute it on the date set forth below. I also understand thatthe terms herein are contractual and not a mere recital, and that I have signed this document of my own free act.

Today's Date: April 25, 2024 

First Participant's Name

First Name*

Middle Name

Last Name*

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Third Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Fourth Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Fifth Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Sixth Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Seventh Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Eighth Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Ninth Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
Tenth Participant's Name

First Name*

Middle Name

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

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

DIVER INFORMATION 


Certification Card No:

Certifying Agency:

Highest Certification Level:

Approximate no. of dives to date:

Location of last dive:

Date of last dive (Re-activate Course is required if last dive was >2 years ago): *
Preferred tank-fill:*
Nitrox
Air

Nitrox Certification No:
Regulator Kind Used:*
No, I am renting a Regulator from Sam's Tours
DIN
YOKE
I'm not sure

Dive Insurance Provider:

Insurance Policy No.:

Emergency Contact


Emergency Contact Name *

Relationship to Participant: *

Telephone Number of Emergency Contact (+1 101 111 0000) *

Email Address of Emergency Contact: *
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 - TRY IT FREE!