Online Indemnity Form IndemnityFirst NameLast NameDate of BirthAddressAddress Line 1CityStateCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhone/MobileEmailDive QualificationNitrox Certified Yes NoDate of Last DiveNumber of DivesTravel Insurance / Medical NameInsurance Contact NamePolicy NumberInsurance Contact EmailEmergency Contact NameEmergency Contact NumberIndemnity I do hereby acknowledge that I am aware of the risks and dangers involved in SCUBA diving and SHARK diving and of myself sustaining an injury or being lost during the dive, including my attendance at supervised training courses. I further acknowledge that I am aware of the risk and dangers involved in being a passenger on a boat of any type, launching from the beach or river-mouth into the sea and traveling at sea. I am, prepared to be exposed to these risks and dangers, with the possibility of being lost, injured or dying, and partake in the events of my own free will. In the event of myself being injured or lost, the most qualified in the group will have the right to decide on what way I should be treated or, if necessary, be evacuated, and I further accept that I will be liable for the cost of such. I further acknowledge that I am aware of the risks of traveling on the back of a vehicle to and from the launch site and launching through the surf. I accordingly renounce, waive and reject any and all statutory and common-law rights and claims that I may have against S & B LEISURE and or any of their staff arising from any loss or damage to equipment, be it owned , or rented or borrowed and any injury or disablement whatsoever sustained by me or my death occurring during the course of my participation in the dive, and the transporting to and from the dive site by vehicle or boat whether this is due to any negligence, fault, omission or the like, on the part of any person. I do voluntarily assume the risk of diving and make this renunciation of my own free will. I further acknowledge that as a qualified diver, I am responsible for my own air and bottom-time. I will abide by the lost diver procedure and the bottom time stipulated by the dive master at the briefing before the dive. I hereby list below those medical conditions and/or medication with which I am being treated which in the event of an accident will assist those treating me.Do you have any medical conditions ? Yes No Medical Conditions I further acknowledge I am medically fit for surf launch and for all scuba diving activities to the declared level of my diving qualification.DateFull Signature Sign Here Full Signature of Guardian if under 21 years old Sign Here Submit Form