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FOR OFFICE USE ONLY EXPERIENCED JUMPER INFORMATION PVAS #: ________________ FIRST NAME: _____________________ LAST NAME: _______________________________ Home Address: ___________________________________________ CITY: _________________________ State/Provence: ______________________ Post Code: ____________ Country: ___________________ Home Ph#: __________________________________ Cell Ph#: __________________________________ (if international, please include country & city codes) (if international, please include country & city codes) E-Mail: _________________________________________________________________________________ Birthdate: __________________________ Weight: _________________ Height: _________________ (Month / Day / Year) Driver's License # or Foreign Passport #: _______________ Occupation: __________________________ SKYDIVING MEMBERSHIP INFORMATION USPA #: _______________ Expiration Date: _______________ License #: ____________________ If Temporary USPA issued... Date Issued: __________________ Expiration Date: __________________ or Foreign Membership #: ________________________ Expiration Date: __________________________ EMERGENCY CONTACT INFORMATION Please list at least one person who can be contacted other than friends you are here jumping with (We provide this information to emergency medical personnel in case of an injury) 1. Name: _______________________________________ Relationship: _________________________ Home Ph#: ____________________________ Cell/Work Ph#: ________________________________ (if international, please include country & city codes) (if international, please include country & city codes) 2. Name: _______________________________________ Relationship: _________________________ Home Ph#: ____________________________ Cell/Work Ph#: ________________________________ (if international, please include country & city codes) (if international, please include country & city codes) PERSONAL EMERGENCY INFORMATION Health Insurance Carrier: __________________________________ Policy #: _____________________ Do you take any medications (please list): ____________________________________________________ ______________________________________________________________________________________ Are you allergic to any medications (please list): _______________________________________________ ______________________________________________________________________________________ PERSONAL SKYDIVING GEAR INFORMATION - FOR OFFICE USE ONLY Reserve Repack Date: ______________________________ SQ1 Initials: ______________________ IMPORTANT LEGAL DOCUMENT READ CAREFULLY WAIVER OF LIABILITY, ASSUMPTION OF RISKS COVENANT NOT TO SUE, AND INDEMNITY AGREEMENT WARNING!!!! By signing this document you are giving up valuable legal rights in the event you should be injured and you or your family attempt to sue someone for your injuries. FURTHERMORE, there is no insurance coverage provided by the Released Parties for any injuries that may happen to you while parachuting, skydiving, riding in aircraft, or just being a bystander on the airport premises. This document is intended to waive and release your and your family’s right to make claims for your injuries or to collect upon any insurance benefits. NOTICE!!!! There are a number of other parachuting operations where you may choose to go if you do not want to sign this WAIVER OF LIABILITY, ASSUMPTION OF RISKS, COVENANT NOT TO SUE, AND INDEMNITY AGREEMENT. Ask for the list if you do not want to sign this document and it will be furnished to you. DO NOT SIGN THIS DOCUMENT until after you have seen the videotape "The Perris Valley Airport, Inc. Waiver Video" and you have had an opportunity to think about the consequences of signing this document and fully understand its importance and its binding effect upon you and your family and heirs. IMPORTANT LEGAL DOCUMENT READ CAREFULLY _______________________________________ Signature _______________________________________ Print Name _______________________________________ Date July 2011 WAIVER OF LIABILITY, ASSUMPTION OF RISKS COVENANT NOT TO SUE, AND INDEMNITY AGREEMENT In consideration for being permitted to utilize the facilities and equipment and personnel at the Perris Valley Airport and to engage in parachute jumping, ground instruction, flying in aircraft, and related activities (thereinafter referred to "Parachuting Activities"), I, ______________________________________________________________ (Print Name), for myself, my heirs, my personal representatives, and/or assigns, HEREBY AGREE TO THE FOLLOWING: 1. I HEREBY FOREVER RELEASE AND DISCHARGE (________) INITIAL the Perris Valley Airport, Inc., the land owners of the Perris Valley Airport, Ben Conatser, Diane Conatser , Pat Conatser, Melanie Peschio, Conatser FamilyTrust, Perris Valley Aviation Services, Inc., Perris Valley Skydiving School, Inc., P.M. Leasing, Inc., Bombshelter Bar & Grill, the owners or operators of any aircraft or land used in any way for the Parachuting Activities, their independent contractors, their instructors, pilots, and jumpmasters, Square One Parachute Sales & Service, any and all concessionaires of the Perris Valley Airport, Inc., the United States Parachute Association, and each of their respective officers, directors, shareholders, partners, agents, and employees (hereinafter collectively the “Released Parties”) (________), INITIAL FROM ANY AND ALL CLAIMS AND LIABILITY including but not limited to the negligence, whether active or passive, or breach of any other duty or obligation imposed by law, of any of the Released Parties, including those acting on their behalf, resulting in personal injury (including death), accidents, illnesses, and property or pecuniary loss arising from but not limited to, my participation in the Parachuting Activities, except where caused by gross negligence or willful or wanton misconduct of any of the Released Parties. (________). INITIAL 2. I intend for this Agreement to be binding upon me regardless of when I participate in the Parachuting Activities. By signing this Agreement I confirm, agree and accept that its terms are fully binding even for my participation in the Parachuting Activites subsequent to this date, even occurring years subsequent. I agree that whenever I engage in the Parachuting Activities, this Agreement is and will be fully applicable. (________). INITIAL 3. I intend for this Agreement to apply to any of my relatives, personal representatives, heirs, beneficiaries, and next of kin or assigns or any other person who might pursue any legal action or claim regarding my injuries on my behalf or for their injuries that are or might be derivative of mine. (________) INITIAL 2 July 2011 4. I further agree that I WILL NOT SUE OR MAKE A CLAIM against the Released Parties or any of them for damages or other losses sustained as a result of my participation in Parachuting Activities (________). INITIAL 5. I FURTHER AGREE TO INDEMNIFY AND HOLD THE RELEASED PARTIES HARMLESS from all claims, judgments and costs, including attorney's fees, incurred in connection with any claim or action brought by me or on my behalf or as a result or consequence of my participation in Parachuting Activities (________), including but not limited to losses INITIAL caused by the active or passive negligence of the Released Parties, including those acting on their behalf, or caused by hidden, latent, or obvious defects on the drop zone or in the equipment or aircraft used in the Parachuting Activities. I FULLY UNDERSTAND THAT THE INTENT OF THIS AGREEMENT IS TO RELEASE AND DISCHARGE AND HOLD HARMLESS THE RELEASED PARTIES FROM ANY DUTY OF CARE TO ME WHAT- SO-EVER IN SO FAR AS IT IS POSSIBLE TO DO SO UNDER THE LAWS OF THE STATE OF CALIFORNIA. (________) INITIAL 6. I understand and acknowledge that Parachuting Activities have inherent dangers that no amount of care, caution, instruction or expertise can eliminate and I EXPRESSLY AND VOLUNTARILY ASSUME ALL RISKS ASSOCIATED WITH PARACHUTING ACTIVITIES including the risk of passive or active negligence of the Released Parties, including those acting on their behalf, and of hidden, latent, or obvious defects on the drop zone or in the equipment or aircraft used. (________) INITIAL 7. I recognize and fully accept that Parachuting Activities are not covered by any personal accident or general liability or life insurance policy maintained by the Released Parties (________). INITIAL 8. I understand that because of the unavoidable and unpredictable dangers involved in the use of parachutes the Released Parties are making NO WARRANTY OF ANY KIND, WHETHER EXPRESS OR IMPLIED, CONCERNING ANY AND ALL EQUIPMENT, AIRCRAFT, DROP ZONE OR FACILITIES PROVIDED by the Released Parties, or by those acting on their behalf, and I further understand and accept that parachuting is a dangerous sport and that associated equipment, such as PARACHUTES, DO NOT ALWAYS WORK the way they are expected to. Furthermore, I understand that my stability and body position can drastically affect the operation of the parachute. I also understand and accept the dangers and risks associated with airborne or ground collisions between myself and other parachutists or equipment, which collisions may occur at any time during Parachuting Activites. (________) INITIAL I understand that the parachutes provided by the Released Parties are provided without any warranty that they are fit to use for any purpose whatsoever, without the warranty of merchantability and in particular without any warranty that they are fit to use in descending from an

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