5015 Penn Ave South Minneapolis, Minnesota 55419 (612) 925-4818
1571 Century Point Eagan, Minnesota 55121 (651) 681-8434
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5015 Penn Ave South Minneapolis, Minnesota 55419 (612) 925-4818 1571 Century Point Eagan, Minnesota 55121 (651) 681-8434
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Atlantis Dumaguete - Philippines This application must be completed by each applicant for a SCUBA CENTER/Tom Pederson travel program. It should be returned with a deposit of $300. Cancellations are subject to a cancellation fee. _________________________________________
________________ Mr./Ms._________________________________________________________ ________________________________________________________________ ________________________________
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___________________________ ____________________________ E-mail Address ____________________________________________ PASSPORT INFORMATION ___________________
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______________________________ _______________________________ In the event of an emergency, please list the person we may contact on your behalf: _________________________________________
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__________ _________________ What source led you to this SCUBA CENTER/Tom Pederson Adventure? ________________________________________________________________________________ Which SCUBA certification do you hold? ________________________________________________________________________________ Please give a brief summary of your diving experience. ________________________________________________________________________________ ________________________________________________________________________________ Do you have any medical history, medical condition or medical impairment which would make diving dangerous, hazardous, or expose you to exceptional risk? _______________________________________________________________________________ _______________________________________________________________________________ Smoker Non-Smoker Any special dietary requests? ____________________________ If you are traveling alone and wish to share a room, would you object to sharing one with a member of the opposite sex? Yes No We will do our best to accommodate your request, but cannot guarantee that you will share a accommodations with someone of the same sex. You can only be guaranteed a private room if you indicate your willingness to cover the expense of a single room I understand and agree to pay the cost of a single supplement. _____________________________
___________________ HAVE YOU COMPLETED ALL BLANKS? THE INFORMATION REQUESTED ON THIS FORM IS ESSENTIAL TO THE PROCESSING YOUR APPLICATION. ______________________ GENERAL CONDITIONS General Release, Assumption of Risk, Waiver of Liability and Indemnity Agreement NOTE: Trip cancellation insurance may be purchased through Scuba Center or any travel agent for a nominal premium. We urge you to purchase such insurance and read the policy carefully. Information is available at Scuba Center. Agreement of Liability and Responsibility and Release I hereby understand and agree to the above General Conditions and to the following terms and conditions of participating in a Scuba Center/Tom Pederson program. 1. Liability and Release: In traveling to and from any dive destination and during the trip itself, there are certain risks and dangers, including but not limited to hazards arising from the forces of nature, from living on board ship, from accident or illness without medical facilities, and from travel itself. In consideration of, and as part payment for, the right to participate in this trip, I assume all risks of harm, injury and damage to myself and my personal property arising out of my preparation for and participation in this trip. I agree to hold Scuba Center and Tom Pederson harmless from, and to indemnify them against, any and all claims, liabilities, obligations, and causes of action of whatever kind or nature for injury to me, of my death and for any and all damage to, or destruction of my personal property, resulting from any and all negligent acts or omissions of Scuba Center, Tom Pederson or its employees, agents, contractors or invitees. 2. Suppliers of Services: Scuba Center and Tom Pederson are performing a service by making known to potential participants worthwhile scuba trips. But, Scuba Center and Tom Pederson are acting independently and have no business association as partner or joint venture with any boat owner, resort, hotel, carrier or other supplier of sail or other transportation or other services. Any and all claims for inadequate or non-performance of such services may be made against the supplier of those services but shall not be made against Scuba Center and/or Tom Pederson. 3. All programs are subject to change as to date, itinerary and price. Substitutions on a given program are not considered cancellation by Scuba Center or Tom Pederson. No refunds can be made for cancelled diving arrangements due to adverse weather, or for substitution of facilities and/or equipment, or for minor inconvenience. Applicant declares that Applicant has read and understands the contents hereof and voluntarily signs the General Release, Assumption or Risk, Waiver of Liability and Indemnity Agreement. _________________
___________________________________________________________ Send or fax application to: SCUBA CENTER DIVE TRAVEL, 5015 Penn Avenue South, Minneapolis, MN 55419 SCUBA CENTER Phone: (612) 925-4818 FAX: (612) 925-5933 Tom Pederson Phone: (952) 925-3015 E-mail: topederson@comcast.net |
