LETTER OF CONSENT FOR WAIVER OF LIABILITY
IN THE EVENT OF AN ACCIDENT OR INJURY, A CLAIM FOLLOWED BY AN INCIDENT REPORT FROM CUSTOMER DOCUMENT MUST BE SUBMITTED THE
DAY OF YOUR JUMP. ANY CLAIMS MADE AFTER THIS DATE WILL NOT BE ACCEPTED
I confirm that I,

have read the important information in all the terms (1-12) below about bungy jumping that is managed byBungy Japan K.K. (hereinafter “Organizers”). Further, I confirm that I fully understand the inherent risks of bungy jumping, and that I fully understand,accept and agree to the rights of the Organizers and the content of its insurance policy for said bungy jumping. Further, I am signing this agreement
voluntarily.
1. I fully understand & acknowledge that participating in bungy jumping has inherent risks, including but not limited to physical injury & even death.
2. I agree to observe and obey all the conditions necessary to participate in bungy jumping (including; being over 15 years old; being within the weight
range of 40kg to 105kg; and being in good health). I assert that I have no injury or disease that would affect my ability to safely participate as s uch. I
also agree to refrain from participating in bungy jumping when I am pregnant or under the influence of alcohol. I also understand and acknowledge that if I
conceal an illness or injury, when participating in bungy jumping, the insurance policy as stipulated in article 3 shall not apply to me and that I shall be
liable for my own acts (and omissions), accordingly.
*Customers who have low bone density, weak bone and/or osteoporosis will not be allowed to participate in bungy jump activity.
There is a danger that you could brake and/or injured your bone under strong pressure on doing bungy jump.
If a claim is made that relates to any broken bones the customer must submit to a Bone Density or DXA (noninvasive) Test.
3. I understand the Organizers provides the following insurance cover for:
Death or residual disability : 5 million JPY
I also understand and acknowledge that this insurance policy does not include the costs of medical care, transportation or property damage.
4. I agree to observe and obey all posted rules, to follow any instructions or directions given by the Organizers through its staff, and to be fully aware of
all safety matters. I also understand and acknowledge that if I do not observe and obey the said rules and instructions given by the Organizers, theOrganizers has the right to cancel my participation in bungy jumping, and that I shall be liable for my own actions (and omissions), accordingly.
5. I intend my signature to be a complete and unconditional release of all liability for the Organizers and its staff due to act of god (including unpredictednatural phenomenon).
6. I also understand and acknowledge that I shall be liable to pay the repair and/or replacement costs for any damage to the the Organizers’ property thatis caused in whole or part by my intentional acts or omissions, or my failure to observe the rules and instructions given by the Organizers and its staff toany facilities or equipment operated and managed by the Organizers.
7. I consent to medical care and transportation as the Organizers or medical professions may deem appropriate in order to obtain treatment in the eventof my falling ill or becoming injured during my participation in the bungy jumping.
8. I consent to the the Organizers’ use of my image at no cost in photographs, motion pictures or recordings taken at any of the Organizers’ bungy
jumping sites for use in the Organizers’ advertising, marketing or promotion throughout the world.
9. I agree that the Organizers’ reserves the right to cancel bungy jumping in the event of inclement weather, natural or man-made disasters, acts of god
or for any other reason that the Organizers deem, at its discretion, necessary for safety & security of participants or due to difficulty of operating bungyjumping.
10. In the event that purchased photo packs cannot be provided, only a full refund of the photo pack will be given.
11. If I am under 18 years old I agree that I have provided Bungy Japan staff with a LETTER OF CONSENT FOR WAIVER OF LIABILITY signed by myparent/guardian including their relationship to me.
12. In the event of an accident or injury, a clam followed by an incident report from customer document must be submitted the day of your jump.
Any claims made after this date will not be accepted.

Date/

/

Have you had any previous experience

Yes ・ Nobungy jumping
Date of birth/

Are you under the influence/(AgeYes ・ Noof alcohol or drugs

Sex

M･F

Pre-existing illnesses or injuries(e.g. heart disease, broken bones)

Are you

Yes ・ NopregnantName)

If yes, please describe
your illness or injury(print)Telephone number/
Emergency contact number

Signature
Address〒

Parent/Guardian signature（Required if participant is under the age of 18）

Relationship toparticipant:Yes ・ No