Upstate Diving Diver Registration
This registration form is for all divers at Upstate NY Diving. After completing the form you will be contacted by Upstate NY Diving to confirm your diving evaluation and practice times for you child.
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Email *
Diving Location *
Diver First Name *
Diver Last Name *
Diver Gender *
Diver's Birthdate *
MM
/
DD
/
YYYY
Diver's School District *
Please list school district even if attending private school or home schooled.
Diver's High School Graduation Year *
Parent or Guardian First Name *
Parent or Guardian Last Name *
Parent or Guardian Phone number *
Parent or Guardian Billing Email Address *
Street Address *
City or Town *
Zip Code *
Diver Allergies & Medical Conditions
Please list any allergies or medical conditions. List N/A if no allergies or medical conditions exist.
Emergency Contact Name *
Must be different than parent name contact above
Emergency Contact Phone Number *
Must be different than parent contact number above
PHOTO RELEASE ACCIDENT WAIVER AND RELEASE OF LIABILITY *
I give permission for Upstate New York Diving to photograph/videotape my child during practices and competitions, for use as promotional material in print publications, and the Upstate NY Diving Website.  This consent is granted for a period of one (1) year. I HEREBY ASSUME ALL OF THE PARTICIPATING AND/OR VOLUNTEERING IN PRACTICES, COMPETITION AND OTHER ACTIVITIES ORGANIZED BY UPSTATE NEW YORK DIVING, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by either UPSTATE NEW YORK DIVING or ROCHESTER INSTITUTE OF TECHNOLOGY, or because of their possible liability without fault. I certify that I am physically fit, have sufficiently prepared or trained for participation in the activity or program, and have not been advised to not participate by a qualified medical professional. I certify that there are no health related reasons or problems which preclude my participation in this program. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity or event in which I may participate, and that it will govern my actions and responsibilities at said program. In consideration of my application and permitting me to participate in this program, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability  arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: UPSTATE NEW YORK DIVING or ROCHESTER INSTITUTE OF TECHNOLOGY and/or their directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, activity or event volunteers; (B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise. I acknowledge that UPSTATE NEW YORK DIVING and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific event or activity on behalf of UPSTATE NEW YORK DIVING. I acknowledge that this activity may involve a test of a person’s physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by facilities, temperature, condition of participants, equipment, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, officials, and program monitors, and/or producers of the program, and lack of hydration. These risks are not only inherent to participants, but are also present for volunteers. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during participation in the program. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. The undersigned parent and natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward’s participation in the activity or event, and has agreed individually and on behalf of the child or ward, to the terms of the accident waiver and release of liability set forth above. The undersigned parent or guardian further agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.
Required
Participant Prior Diving Experience *
Participant Prior Gymnastics Experience *
AAU Membership Number *
Please enter your AAU membership number for the current year.
Free Evaluation Code
Referred by:
If you were referred by an Upstate Diver  please list their name here.
A copy of your responses will be emailed to the address you provided.
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