Ciba Waiver Form

1
Full Name* This field is required.
2
Street Address
3
City
4
State
Please Select
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
5
Zip Code
6
Phone Number* This field is required.
7
E-mail Address* This field is required.
8
Are you 18 years of age or older?* This field is required.
YESNO
9
Date of Birth* This field is required.
Month
Day
Year
10
EMERGENCY CONTACT INFORMATION
11
Contact Name* This field is required.
12
Contact Phone Number* This field is required.
13
Relationship
Please Select
Please Select
Spouse
Sibling
Parent
Friend
14
Ciba USER TERMS AND CONDITIONS* This field is required.
15
Ciba Liability Waiver and Release Consent* This field is required.
16
Signature of Participant* This field is required.HAVING CAREFULLY READ CIBA USER TERMS AND CONDITIONS, LIABILITY WAIVER, RELEASE CONSENT AND UNDERSTANDING IT TO BE A LEGALLY BINDING RELEASE AND INDEMNITY AGREEMENT, PARTICIPANT SIGNIFIES HIS ASSENT TO THE ABOVE TERMS BY SIGNING BELOW:
Clear
17
Signature Date* This field is required.
Date
Year
Month
Day
18
Parent or Legal Guardian Permission* This field is required.
19
Signature of Parent or Legal Guardian* This field is required.HAVING CAREFULLY READ THE FOREGOING AND UNDERSTANDING IT TO BE A LEGALLY BINDING RELEASE AND INDEMNITY AGREEMENT, PARTICIPANT SIGNIFIES HIS ASSENT TO THE ABOVE TERMS BY SIGNING BELOW:
Clear
20
Signature Date of Parent or Legal Guardian* This field is required.
Date
Year
Month
Day
21
Type of Purchase* This field is required.
Day Pass
Filling out the waiver
Day Pass
PrePaid Membership
Single Membership
Family Membership
Kids Club
Outdoor Guiding
Should be Empty: