Guest registration form

First name

Last name

Date of birth / age

Swimming ability

Street address

City

State / ZIP

Phone

Emergency contact name

Emergency contact relationship

Emergency contact primary phone

Emergency contact alternate phone

Known medical conditions, allergies, or medications

Mobility limitations or special assistance required

Photo / video consent

Safety acknowledgement initials: *I acknowledge that I have received safety briefings, will follow the Captain’s instructions, and will wear provided lifejackets when required.

Guest signature (type full name)

Guest signature date (MM/DD/YYYY)

If minor: Parent/guardian printed name

If minor: Parent/guardian signature (type full name)

If minor: Parent/guardian signature date (MM/DD/YYYY)

View the Waiver (PDF)

Waiver signature (type full name)

Waiver date (MM/DD/YYYY)

If minor: Minor's name

If minor: Parent/guardian waiver signature (type full name)

If minor: Parent/guardian waiver date (MM/DD/YYYY)

Primary physician

Physician phone

Medical conditions (emergency)

Allergies (emergency)

Medications (emergency)

Insurance provider / Policy #

Can the crew administer basic first aid/CPR?

Special instructions

Medical authorization

Medical authorization printed name

Medical authorization date (MM/DD/YYYY)

If minor: Parent/guardian medical authorization printed name

If minor: Parent/guardian medical authorization signature (type full name)

If minor: Parent/guardian medical authorization date (MM/DD/YYYY)