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Statement of Risk and Liability/ Non-agency Acknowledgment Form

GENERAL TRAINING

Please read carefully and fill in all blanks before signing Non-Agency Disclosure and Acknowledgment Agreement.

I understand and agree that PADI Members ("Members"), including La Jolla Dive / Zach's Scuba Shack and/or any individual PADI Instructors and Divemaster's associated with the program in which I am participating, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of PADI EMEA Ltd., PADI Americas, Inc., or its parent, subsidiary and affiliated corporations ("PADI").

  I further understand that Member business activities are independent, and are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver training programs, it is not responsible for, nor does it have the right to control, the operation of the

Members' business activities and the day-to-day conduct of PADI programs and supervision of divers by the Members or their associated staff.

Statement of Risk and Liability

   This is a statement in which you are informed of the risks of skin and scuba diving. The statement also sets out the circumstances in which you participate in the diving programme at your own risk.

Your signature on this statement is required as proof that you have received and read this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then please discuss it with your instructor. If you are a minor, this form must also be signed by a parent or guardian.

Warning

Skin and scuba diving have inherent risks which may result in serious injury or death.

Diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. Open water diving trips that are necessary for training and for certification, may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber.

Skin and scuba diving are physically strenuous activities and you will be exerting yourself during this diving programme. You must advise truthfully and fully inform the dive professionals and the facility through which this programme is offered of your medical history.

Acceptance of Risk

I understand and agree that neither the dive professionals conducting this programme, nor the facility through which this programme is conducted, La Jolla Dive / Zach's Scuba Shack, nor PADI EMEA Ltd., nor PADI Americas, Inc. nor their affiliate or subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns accept any responsibility for any death, injury or other loss suffered by me to the extent that it result

from my own conduct or any matter or condition under my control that amounts to my own contributory negligence.

In the absence of any negligence or other breach of duty by the dive professionals conducting this programme, the facility through which this programme is offered, La Jolla Dive / Zach's Scuba Shack, PADI EMEA Ltd., PADI Americas, Inc. and all parties referred to above, my participation in this diving programme is entirely at my own risk.

I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND

ACKNOWLEDGMENT AGREEMENT AND STATEMENT OF RISK AND LIABILITY BY READING BOTH BEFORE SIGNING THESE STATEMENTS.

First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Emergency Contact

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First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Emergency Contact

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Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Emergency Contact

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Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Emergency Contact

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Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Emergency Contact

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Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Emergency Contact

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Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Emergency Contact

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Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Emergency Contact

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Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Emergency Contact

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Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Emergency Contact

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Parent or Guardian's Email Address

Email*

Confirm Email*
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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*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Emergency Contact

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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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