Mental Health Bodily Injury
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Smartwaiver Certificate of Authenticity
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Document ID: 9JX84tqD7da2PhPaNXZ2h6
Completed: 2024-07-22T21:10:50+00:00 UTC
CENTRAL COAST KAYAKS
**** ***** ***** **. ****L BEACH, CA 93449
Liability Release, Assumptions of Risk, and Indemnity Agreement Today's Date: July 22, 2024
In consideration of Central Coast Kayaks services and/or equipment for me to participate in outdoor activities, programs, expeditions, and/or courses planned or supervised by Central Coast Kayaks I agree as follows: I understand that outdoor activities have inherent risks, dangers, and hazards and such exists in my use of Central Coast Kayaks equipment and my participation in outdoor activities, programs, expeditions, and/or courses planned or supervised by Central Coast Kayaks. AND I understand that certain skills, abilities, and physical and mental health are required in order to reduce the dangers involved in kayaking; I confirm that I possess such skills, abilities, and health required to participate in such activities.
I understand that my participation in such activities and/or use of such equipment may result in illness or injury including but not limited to bodily injury, disease, fractures, strains, partial and/or total paralysis, death or other ailments that could cause serious disability.
I understand that these risks and dangers may be caused by the negligence of the owners, employees, officers, or agents of Central Coast Kayaks; the negligence of the participant, the negligence of others, accidents, breaches of contract, the forces of nature, or other causes. Central Coast Kayaks personnel have difficult jobs to perform. They seek safety but are not infallible. They might be unaware of a participant’s fitness or abilities. Risks or dangers may arise from foreseeable or unforeseeable causes including, but not limited to, guide/instructor decision-making including that they may misjudge terrain, weather, trail, sea conditions, surf or tides, and currents, risks of falling out of or drowning while in a kayak and such other risks, hazards, and dangers, that are integral to recreational activities that take place in a wilderness, outdoor, marine, or recreational environment.
I understand that my participation in these activities and use of the equipment I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or other conduct of the owners, agents, officers, or employees of Central Coast Kayaks, or by any other person I, on behalf of myself, my personal representatives, and my heirs hereby voluntarily agree to release, waive, discharge, hold harmless; defend and indemnify Central Coast Kayaks, the city of Pismo Beach, Grover Beach, San Luis Harbor District, and the County of San Luis Obispo, and its owners, agents, officers, and employees from any claims, actions, or losses for bodily injury, property damage, wrongful death, loss of services, or otherwise, which may arise from Central Coast Kayaks equipment or my participation in kayaking activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers, or employees of Central Coast Kayaks.
IP: 73.90.132.58 Email: ********@*****.*** Version: 1.0.0.20190102 Page 1 of 5 Damon
First Name*
Reite
Last Name*
Phone*
2 - February 4 1975
Any controversy arising out of or pertaining to this agreement, or its scope, interpretation, application, enforcement, or alleged breach, shall be resolved through binding arbitration administrated through an arbitration provider in San Luis Obispo County unless otherwise agreed upon. Each side shall bear the expense of the arbitration proceeding equally unless otherwise agreed upon. The arbitration proceedings shall be governed by California Code of Civil Procedure 1280 et seq. in effect at the time of arbitration or any other rules the parties mutually agree upon in writing. Any award of the Arbitrator(s) may be entered as a judgment in any court having jurisdiction.
Furthermore, I do authorize Central Coast Kayaks, to photograph, televise, videotape, or by any other means record the image or voice of the participant while engaged in any activity planned or promoted by Central Coast Kayaks, and to use such records for instructional, promotional, or commercial use. Any reproduction for commercial use by anyone other than Central Coast Kayaks is prohibited.
I HAVE READ THE ABOVE WAIVER AND RELEASE. BY SIGNING IT I AGREE TO EXEMPT AND RELIEVE CENTRAL COAST KAYAKS FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WONDERFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.
Participant's Name
Participant's Date of Birth*
Participant's Information
IP: 73.90.132.58 Email: ********@*****.*** Version: 1.0.0.20190102 Page 2 of 5 Click to customize drop-down*
Jul 23, 2024
Tour/Class Date *
If yes, did you/will you take motion sickness medication before your tour/class? If yes, please rate your swimming ability:
Expert
Other allergies (please list)
If yes to any of the above, please describe your allergic reaction and how you treat it: Other:
Do you get seasick?*
• No
Yes
Can you swim?*
No
• Yes
Are you allergic to any of the following? (Check if "yes") Medication
Food
Insects
Do you have a history of any of the following?
Abnormal Blood Pressure
Arthritis
Asthma
Diabetes
Dizziness
Hearing Loss
Joint Pain
Migraines
Mobility Issues
Poor Circulation
Poor Eyesight
Seizures
Stomach Problems
Unconsciousness
IP: 73.90.132.58 Email: ********@*****.*** Version: 1.0.0.20190102 Page 3 of 5 If yes to any of the above, have you been treated? Are you currently taking any medications that you feel we should be aware of? If yes, please list. 831 S. Pinkham St.
N/A
United States
Visalia
CA
93292
********@*****.***
Email*
Please make sure you have any necessary medical items (i.e. EpiPen) with you! Participant's Signature*
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:*
Email Address
Emergency Contact
IP: 73.90.132.58 Email: ********@*****.*** Version: 1.0.0.20190102 Page 4 of 5 Damon
First Name*
Reite
Last Name*
Emergency Contact's Phone Number*
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. IP: 73.90.132.58 Email: ********@*****.*** Version: 1.0.0.20190102 Page 5 of 5
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