Liability Release - Roddenberry.com

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I declare under penalty of perjury that all statements made by me in this Agreement are true and I willingly sign this Acknowledgment and Express Assumption of Risk and Release of Liability. _________________________________ ________________________ Signature Date Printed Name Scuba Certification Number: _________________________________________ Scuba Certification Agency/Instructor: _________________________________ IF PARTICIPANT IS A MINOR: If Dive Team Event participant is a minor, a signature of a parent or legal guardian who is a certified scuba diver and who will be accompanying the minor on the Dive Team Event must be provided below. By this signature, such parent/legal guardian confirms that the minor is at least fifteen (15) years of age and: (a) agrees to, ratifies and confirms, on behalf of such minor, the terms and conditions of this Acknowledgment and Express Assumption of Risk and Release of Liability and all Exhibits attached hereto; (b) represents and warrants that he/she is a certified scuba diver; and (c) agrees that he/she shall be participant's dive buddy/partner and supervisor for all activities throughout the course of each of the entire Dive Team Events. Such parent/legal guardian understands and agrees that the signature provided below and the agreements and representations set forth in this paragraph are each and all a material inducement to allowing such minor to participant in each of the Dive Team Events. __________________________ Parent/Legal Guardian Signature ____________________________ Printed Name Scuba Certification Number: _______________________________ Scuba Certification Agency/Instructor: ________________________________________ 4
EXHIBIT A EMERGENCY MEDICAL RELEASE IN CASE OF EMERGENCY, by signing below, I authorize Roddenberry Dive Team, Inc., any of its parent or subsidiary corporations or affiliates, and any of their employees, representatives, and contractors to arrange for or provide such medical assistance to me as they determine to be necessary or advisable. I also authorize any licensed physician and/or medical facility to provide any medical/surgical care and/or hospitalization to me, including anesthetics, which they determine necessary or advisable, pending receipt of a specific consent from me. I authorize any reasonably necessary care by the paramedics. I list all known allergies and existing medical conditions here: DATE: _____________________ SIGNED: ________________________________ Print Name:______________________________ Driver’s License No./State:___________________ If Minor, Signature of Parent/Legal Guardian: Printed Name of Parent/Legal Guardian: Medical Insurance Company: ______________________________________________ Name of Policy Holder: __________________________________________________ Policy Number/Group Number: ____________________________________________ Primary Physician: _____________________________________________________ Emergency Contact Name: _______________________________________________ Address: _________________________________ City: ___________________________________ Daytime Phone: (_____) ___________________ Evening Phone: (_____) ____________________ CC1:792876.9 5
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Page 3: 7. I AUTHORIZE RODDENBERRY TO PROVI

Liability Release - Roddenberry.com

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