Participant: 

Address: 

City:    State:    Zip: 

Home Telephone Number:  (no spaces or dashes)  Gender: Select OneMaleFemale

Birth Date:     (xx/xx/xxxx)

In consideration of the acceptance given the undersigned by Thunderbird Diving Club for participation in the Thunderbird Diving Program (“Diving Program”), each of the Participants and/or the parent and/or guardian of the Participant, possessing the legal authority to consent to the Participant’s participation in the ACTIVITY, does on behalf of the undersigned and the Participant, and the Participant’s heirs, executors and administrators, acknowledge and assume the risks inherent in THE ACTIVITY and hereby forever release and discharge THUNDERBIRD DIVING CLUB, its employees, principals, agents, insurers, successors, and assigns, and each sponsor and participating or partnering organization or individuals participating or associated with THUNDERBIRD DIVING CLUB or the diving program, for and from any and all liability, claims, demands, controversies, damages, actions, and causes of action arising out of, or resulting from the Participant’s participation in THE ACTIVITY, including but not limited to all liability, claims, or demands for personal injury, sickness, or death, as well as property damage and expenses arising out of, directly or indirectly, tHE dIVING PROGRAM OR ANY RELATED ACTIVITY OR EVENT (“ACTIVITY”).  Each of the Participants and the undersigned represents that he or she fully understands the intent, meaning and import of this release and has read the same prior to signing.  Each of the Participants and the undersigned, by signing this Release, authorizes the aforementioned parties to provide or furnish any necessary transportation, food, or lodging associated with the activity. 

The undersigned hereby agrees to indemnify and save harmless the aforementioned parties, their employers, employees, principals, agents, insurers, successors, and assigns from any liability incurred by said parties resulting from the negligent, willful, wanton, or intentional acts of the undersigned or the Participant.  The undersigned agrees on behalf of the Participant, to abide by any rules and regulations distributed by the parties, and further agrees, on behalf of the Participant, to adhere to the directions of those in authority and leadership for the ACTIVITY.

By checking this box and typing your name, you confirm that you have read and agree to be bound by the terms and conditions as outlined in the Thunderbird Diving Club “Permission, Waiver and Release” form  (above) and confirm that your electronic signature is the legal equivalent of your hand-written signature.   (electronic signature)   Date:  (xx/xx/xxxx)

Medications:

Allergies, Handicaps, or Limitations:

Emergency Contact Numbers:

Name:   Telephone:  (no spaces or dashes)  Relation: 

Name:   Telephone:  (no spaces or dashes)  Relation: