Fill and Sign the Dangerous Activity Form

Release by a Student Engaging in Dangerous Activity I, _______________________ (Releasor), of _______________________ (street address, city, state), affirm that I have previously completed a certified beginning course of instruction in _______________________ (e.g., scuba diving) prior to enrolling in this course. By enrolling in this course, I certify that I am aware of all of the inherent dangers of _______________________ (e.g., scuba diving), and of the basic safety rules for activities connected with the same. I understand that it is not the purpose of this course to teach safety rules, nor is it the function of the instructors to serve as the guardians of my safety. I also understand that I am to furnish my own equipment and I am responsible for its safety and good operating condition regardless of where I obtain it. I agree that neither owner(s) of this school, operators, employees, agents or instructors (Releasees), may be held liable in any way for any occurrence in connection with _______________________ (e.g., scuba diving) which may result in injury, death or other damages to me or my family, heirs or assigns. In consideration of being allowed to enroll in this course, I personally assume all risks in connection with the course, and I further release the Releasees for any injury or damage that I may incur while I am enrolled as a student of the school, including all risks connected with the same, whether foreseen or unforeseen; and further agree to indemnify and hold harmless the Releasees from any claim by me, or my family, estate, heirs or assigns, arising out of my enrollment and participation in this course. I further state that I am of lawful age and legally competent to sign this release; that I understand the terms in this document are contractual, and that I have signed this document as my own free act. I have fully informed myself of the contents of this release by reading it before I signed it. I have had a medical examination to assure myself, and assume my own responsibility of physical fitness and capability to perform under the normal conditions of an advanced program, and am physically fit as attested to by the medical examination. I have executed this release at (place of execution) on the day of , 20 . Signature of Releasor Acknowledgment before Notary Public