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Acknowledgement of Danger: Release and Hold Harmless Agreement

San Miguel Island (SMI)

Channel Islands National Park 

(This form is subject to the Privacy Act of 1974)
Issuing Agencies—U.S. Navy & National Park Service

AUTHORITY: Federal law, including 10 USC Chapter 159 and associated regulations

PRINCIPAL PURPOSE: Indicates certification by an individual or corporation to hold the U.S. Government, Department of Defense, Department of Interior, and any SMI Lessee or Lessor harmless in consideration of permission granted by the U.S. Government to visit SMI.

ROUTINE USES: Used to gain access to SMI.

DISCLOSURE IS VOLUNTARY: Failure to provide this information would result in an individual or corporation being denied access to SMI.

TERM OF PERMIT: This permit is valid for the current calendar year for SMI. Some areas may be periodically closed due to military operations. 

San Miguel Island is owned by the U.S. Navy and operated by the National Park Service. There are risks inherent in visiting any wild remote place like the Channel Islands. On San Miguel there are additional risks stemming from the island’s historic use as a bombing and missile test range. 

To visit San Miguel Island, you must acknowledge that you have been informed of these risks and that you agree to hold the U.S. Government harmless of any liability. It is therefore important that you read the following carefully before signing: 

SMI contains the danger of property damage and permanent, painful, disabling and disfiguring injury or death due too high explosive detonations from falling objects such as aircraft, aerial targets, live ammunition, missiles, bombs, etc. 

SMI contains the danger of property damage and permanent, painful, disabling and disfiguring injury or death due to the presence of expended, but still live, bombs, rockets, cannon rounds, flares and other types of warheads. Unexploded munitions may be encountered anywhere within SMI: lying on the ground partially or completely buried. These munitions can still explode though they may have lain on the island for decades. I have been instructed NOT to approach or disturb any military equipment or ordnance discovered on SMI. 

In addition to the risks posed by ordnance items, visitors to SMI are also exposed to any or all of the hazards that present on any of the other islands in the National Park. In signing this agreement, I agree to be sure I am informed of and that I abide by all regulations and safety precautions enumerated in park bulletins. 

Upon my own initiative, therefore, and at my own risk, I accept permission to enter this area and in consideration of such permission do, for myself, my spouse, my children, my heirs, personal representatives, and assignees of the same, remise, release, and forever discharge as well as agree to indemnify and hold harmless the United States Government, any lessee therefrom, and individual officer, agent, employee, or director thereof from any claim of liability for injury, death, or property damage arising out of my usage or presence upon said San Miguel Island in accordance with permission to enter thereon. 

I further affirm that I will never prosecute or assist in prosecuting any civil action against the United States Government, the U.S. Navy, the U.S. Department of Interior, or any of their agents, employees, service members, contractors, or lessees for claim or liability arising from my entry to SMI. 

Each adult individual in the group must complete and sign and submit a separate HOLD HARMLESS AGREEMENT AND PERMIT APPLICATION. (Persons under 18 who are not traveling with a parent or guardian must have theirs signed by their parent or guardian as well.) 

I, have received a pamphlet with regulations and procedures for legal access to SMI. I understand that non-compliance with any state and federal laws, and SMI rules and regulations by myself, or anyone accompanied by myself, is a violation of this permit. My access may be revoked or suspended for violations or conduct inconsistent to the management goals of SMI. I CERTIFY THAT BEFORE SIGNING BELOW, I RECEIVED, READ, AND UNDERSTAND THE HOLD HARMLESS AGREEMENT, SMI REGULATIONS.

Date: July 20, 2025

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Permit # 2025--
Work Telephone
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Permit # 2025--
Work Telephone
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Permit # 2025--
Work Telephone
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Permit # 2025--
Work Telephone
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Permit # 2025--
Work Telephone
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Permit # 2025--
Work Telephone
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Permit # 2025--
Work Telephone
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Permit # 2025--
Work Telephone
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Permit # 2025--
Work Telephone
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Permit # 2025--
Work Telephone
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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:*
Additional Information
Booking #
Parent or Guardian's Driver's License / ID Card
Driver's License / ID Card Number*
Issuing State*

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.

If under 18 years of age, a parent or guardian must complete the following acceptance of the above certification:



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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Permit # 2025--
Work Telephone
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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