CONSENT, AUTHORIZATION, AND RELEASE RE: __ (“MINOR ...

CONSENT, AUTHORIZATION, AND RELEASE
RE: __
______________ (“MINOR”)
Date of Birth: _____________________________
THIS CONSENT, AUTHORIZATION, AND RELEASE (“Consent”) is provided to Temple Emanu-El of
Palm Beach in connection with the Beach Kadima Snorkeling Trip with Keylypso of The Palm Beaches Inc.
October 7 th , 2012 (“Scheduled Activity”).
1. The minor has my consent to attend and to participate in the Scheduled Activity. There are no limitations
or restriction of any kind whatsoever on such participation unless this box, _____ is checked with explanation
attached to this form.
2. The Minor has been instructed by me, and understands and agrees, to comply with all rules, regulation,
and Codes of Conduct established by USY and the official instructions and directives of all authorized staff
members, volunteers, agents, and employees (“Personnel”) of USY.
3. You are expressly authorized to administer, prescribe and/or direct the administration of any medication,
other medical treatment, care, surgery, hospitalization or medical procedures and services deemed
appropriate under the circumstances, if you are not able to timely contact me for instructions, acting as my
authorized agent and at my sole cost and expense. There are no exceptions or limitations, or other special
instructions, in connection with the foregoing, unless this box _____ is checked, with explanation attached to
this form.
4. Unless this box _____ is checked and I have provided you with specific instructions, directions or other
specific data to the contrary, on an attached page, you assume that the Minor has no medial disabilities,
allergies or other limitations or any kind whatsoever that might in any way limit participation in the
Scheduled Activity.
5. I expressly release and agree to indemnify and hold USY (and its Personnel) free and harmless from any
and all liability, charges, claims, costs, and expenses of every kind and nature whatsoever, including
reasonable attorney fees, in connection with the acceptance and participation of the Minor in the Scheduled
Activity. The foregoing Release is without reservation of any kind except only for such acts or omissions on
your part that arise out of your intentional or negligent wrongdoing and without fault of any kind on the part
of the Minor or on my part in failing to disclose pertinent information to you.
6. I represent to you that I have the sole, full and legal power and right to execute this Consent, and that you
will rely on my representations.
7. If this consent is signed by more than one person, all references to the singular shall include the plural,
jointly and severally.
I DECLARE UNDER THE PENALTY OF PERJURY THAT I HAVE READ AND FULLY UNDERSTAND
THE IMPORTANCE AND THE EFFECT OF THE FOREGOING CONSENT, AUTHORIZATION, AND
RELEASE: THAT I HAVE OBTAINED SUCH ADVICE OF AN ATTORNEY AND OF A LICENSED
PHYSICIAN AS I DEEMED NECESSARY, TO MY COMPLETE SATISFACTION; AND THAT I
SIGNED THIS CONSENT ON ___________________, 20___.
Signed _____________________________
Relationship to Minor________________ Date ________________
Check here if insurance information has not changed from registration form, if so, please update below.
Insurance Company Name __________________________ Policy Number _____________________
Address ______________________________________________ Phone _________________________

Liability Release, Waiver and Express Assumption of Risk
This is a waiver of your rights to sue
Read carefully before signing
I understand the purpose of signing this document is to exempt and release, Keylypso of The Palm Beaches Inc. and
any of their respective employees, officers, agents, crew, captains, boats and assigns, whether specifically named or
not, (hereinafter referred to as “Released Parties”) and to hold these released parties harmless from any and all
liability arising as a consequence of any act or omission by any of the released parties or any other individual or
entity, including, but not limited to, active negligence, passive negligence and/or gross negligence.
I am aware that there are inherent dangers and risks in snorkeling, swimming, boat use, equipment use, pleasure
boating, fishing and other activities relating to a snorkel trip and/or boat charter (Hereinafter referred to as
snorkeling activities). I understand and agree that this Liability Release, Waiver and Assumption of Risk extend to
all related snorkeling activities, including, entering and exiting the water. I understand and agree that the Released
Parties shall not be held liable or responsible in any way for any injury, death, or other damages to me or my family,
heirs, or assigns that may occur by my participation in any snorkeling activities.
I assert that I am physically fit to participate in all snorkeling activities and I agree that I will not hold any of the
Released Parties responsible if I am injured while participating in any snorkeling activities. I do not have in my
possession any illegal drugs, nor am I taking, nor have I recently taken any drugs, alcohol or medications, which
could cause an adverse reaction as a result of combining such drugs, alcohol and/or medications with snorkeling
activities.
I agree to immediately cease snorkeling if I feel uncomfortable with my snorkeling abilities and/or the conditions are
worse than those for which I am comfortable. I understand that if I want or need any assistance from the boat, I will
give the proper “Snorkeler in Trouble” signal.
I am of lawful age and legally competent to sign this liability release or that I have acquired the written consent of
my parent or guardian. I understand that this is a contract. I have fully informed myself of the contents of this
document. I am voluntarily signing this document and I agree to the terms and conditions herein and realize they are
given in exchange for my participation in snorkeling activities. I understand this Liability Release, Waiver and
Express Assumption of Risk shall be determined according to the laws of the State of Florida and shall be
adjudicated only in Florida courts to the exclusion of any other courts.
IT IS MY EXPRESS INTENTION BY SIGNING THIS DOCUMENT TO GIVE UP MY RIGHT TO SUE
AND TO EXEMPT AND RELEASE KEYLYPSO OF THE PALM BEACHES INC., AND ALL OTHER
RELEASED PARTIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPOSIBILITY
WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFULL DEATH
HOWEVER CAUSED, INCLUDING BUT NOT LIMITED TO, THE ACTIVE NEGLIGENCE, PASSIVE
NEGLIGENCE, AND/OR GROSS NEGLIGENCE OF ANY OF THE RELEASED PARTIES.
________________________________________________________
Signature of Participant
_________________________
Date
________________________________________________________
Print Name
_________________________
Telephone
_____________________________________________________________
Emergency Contact
______________________________________________________________
Parent/Guardian’s Signature