(For adults)□ Discover Snorkeling Statement□ Skin Diving Statement□ Supplied Air Snorkeling Statement
For domestic use in Japan and adult participants only

Participant Record (Confidential Information)
Participant Name:
Mailing Address:
Age:

Phone (Home):

Date of Birth:()(Day/Month/Year)

Postal / Zip:
Phone (Office):()● LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK FOR
DISCOVER SNORKELING● LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK FOR
SKIN DIVING● LIABILITY RELEASE AND EXPRESS ASSUMPTIONOF RISK FOR SUPPLIED AIR SNORKEING

Please read carefully and fill in all blanks before signing.
I, _________________________________________ (Participant Name), hereby
acknowledge that I have been advised and thoroughly informed of the contents of:□ Snorkeling □ Skin Diving □ Supplied Air Snorkeling(Make a check in the appropriate box.),and that I still choose to participate in this Program.
I (Participant) understand that this Program may be conducted at a site such as a sea area, a lake or a pool.
Therefore, in consideration of being allowed to enroll in this Program, I agree to comply with judgement anddirections for safety to be made by the guide(s) or instructor(s).
I understand that this Program is a sport and that I have to be in a good medical condition to participate in it. I
expressly declare that I currently do not have any ear disease, or respiratory or circulatory problem, and that I
have fully explained to the guide(s) or instructor(s) all of my past and present medical history. I hereby agree
that, in case of doubt or upon instruction by the guide(s) or instructor(s), I must consult a doctor and undergo anexamination. I further acknowledge that the participation in this Program is allowed on thecondition that I am not currently taking any medication and that I am in a good physical condition.
I understand that I have to make every possible effort to prevent the risk, and that,
if the worst happens, I have to accept sole responsibility for it.
I have fully informed myself of the contents described above by reading them, and upon
confirmation of all of them,
I hereby sign this LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK.

Name of Participant

成年用ver2.1

Signature of Participant

Date(Day/Month/Year)

(For participants from junior high schoolstudents and up to the age of 19.)

□ Discover Snorkeling Statement□ Skin Diving Statement□ Supplied Air Snorkeling Statement
For domestic use in Japan and participants from junior highschool students and up to the age of 19 only
Participant Record (Confidential Information)
Participant Name:
Mailing Address:
Age:

Date of Birth:

Phone (Home):()

Postal / Zip:
Phone (Office):(Day/Month/Year)()● LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK FOR
DISCOVER SNORKELING● LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK FOR
SKIN DIVING● LIABILITY RELEASE AND EXPRESS ASSUMPTIONOF RISK FOR SUPPLIED AIR SNORKEING

Please read carefully and fill in all blanks before signing.
I(Name of parent or guardian) / my child(Participant Name),
hereby acknowledge that we have been advised and thoroughly informed of the contents of:□ Snorkeling □ Skin Diving □ Supplied Air Snorkeling(Make a check in the appropriate box.),and that we still choose to participate in this Program.
I (parent or guardian) / we (parent or guardian and participant) understand that this Program may be conducted ata site such as a sea area, a lake or a pool. Therefore, in consideration of sending my child to / being allowed toenroll in this Program, we agree to comply with judgement and directions for safety to be made by the guide(s)or instructor(s).
I / we understand that this Program is a sport and that we have to be in a good medical condition to participate init. We expressly declare that we currently do not have any ear disease, or respiratory or circulatory problem, andthat we have fully explained to the guide(s) or instructor(s) all of our past and present medical history.
We hereby agree that, in case of doubt or upon instruction by the guide(s) or instructor(s), we must
consult a doctor and undergo an examination. We further acknowledge that the participation in thisProgram is allowed on the condition that we are not currently taking any medication and that weare in a good physical condition.
I / we understand that we have to make every possible effort to prevent the risk, and that, if theworst happens, we have to accept sole responsibility for it.
I / we have fully informed ourselves of the contents described above by reading them, and upon
confirmation of all of them,
we hereby sign this LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK.
Name of Parent or Guardian
Name of Participant

中学生以上の未成年用

ver2.1Signature of Parent or Guardian

Date (Day/Month/Year)

Signature of Participant

Date (Day/Month/Year)

(For children under junior high school level)□ Discover Snorkeling Statement□ Skin Diving Statement□ Supplied Air Snorkeling Statement
For domestic use in Japan and participants under junior high school level onlyParticipant Record (Confidential Information)
Participant Name:
Mailing Address:
Age:

Phone (Home):

Date of Birth:()(Day/Month/Year)

Postal / Zip:
Phone (Office):()● LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK FOR
DISCOVER SNORKELING● LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK FOR
SKIN DIVING● LIABILITY RELEASE AND EXPRESS ASSUMPTIONOF RISK FOR SUPPLIED AIR SNORKEING

Please read carefully and fill in all blanks before signing.
I hereby certify that, my childadvised and thoroughly informed of the contents of:(Name of Participating Child) has been□ Snorkeling □ Skin Diving □ Supplied Air Snorkeling(Make a check in the appropriate box.),and that, upon full understanding of them, I would like to send my child to this Program.
I understand that this Program may be conducted at a site such as a sea area, a lake or a pool.
Therefore, in consideration of sending my child to the Program selected above, I agree tocomply with judgement and directions for safety to be made by the guide(s) or instructor(s).
I understand that this Program is a sport and that I have to be in a good medical condition toparticipate in it. I expressly declare that I currently do not have any ear disease, or respiratoryor circulatory problem,
and that I have fully explained to the guide(s) or instructor(s) all of my past and present medical history.
I hereby agree that, in case of doubt or upon instruction by the guide(s) or instructor(s), I must consulta doctor and undergo an examination. I further acknowledge that the participation in this Programis allowed on the condition that I am not currently taking any medication and that I am in a good
physical condition.
I have fully informed myself of the contents described above by reading them, and upon
confirmation of all of them,
I hereby sign this LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK.

Name of Parent or Guardian

中学生未満用ver2.1Signature of Parent or Guardian

Date(Day/Month/Year)