PRINT CLEARLY
Date ______Receipt #______
Name(s) ______Age______
______Age ______
______Age ______
______Age ______
Address ______City______
State______Zip______
Driver’s License: State _____ Number______Exp Date _____
Cell Phone:______
PLEASE KEEP CELL PHONE ON. Thank You!
I authorize you to charge my credit card & I agree that a $20/hr LATE FEE will be
charged to my credit card for each kayak returned late! X______
EVERYONE MUST SIGN WAVIER ON BACK
Do not write below this line
------
Description: Type/color/model / Boat # / Out / In / Fee½ Day Full Day Hourly
$ $ $ /hr. / Net
Amount
Pre Paid ____ Cash ____ Charge ____ Total Amount: ______
VISA, MC, DISCOVER & AMEX
CC# ______Expires ______Called in by______
Billing Zip Code ______Name on card______Phone______
Rules, Regulations and Wavier of Liability Agreement
Sutherland Bayou Bait Shack/Sutherland Bayou Boat Ramp
My signature below confirms that I understand and agree to comply with the following
“Rules and Regulations for kayak rental in the preserve as stated below. I also understand that this activity may involve some risks, and that I am liable for loss or damage the rental equipment and for the personal safety of the occupants. I therefore agree that I am assuming all risks in connection with my participation in renting kayaks at Sutherland Bayou Bait Shack/Sutherland Bayou Boat Ramp.
• At least one person in a tandem must be 18 years of age
• Paddle at your own risk; County staff and volunteers, and Sutherland Bayou Bait Shack and it’s staff are not responsible for personal injury or loss of property.
• Florida law requires that children under 6 years of age MUST wear a Personal Flotation
Device (PFD). All others mush have a PFD in their possession.
• All individuals must know how to swim or must be wearing a PFD.
• Do not feed or provoke wildlife.
• Intentional capsizing or swamping is prohibited.
• Equipment must be launched from, and returned to, Sutherland Bayou.
As a condition of my participation, I further agree, represent and warrant to Sutherland Bayou Bait Shack and Pinellas County and its agencies that:
• I have sufficient physical strength, endurance and experience to enable me to participate.
• I do not have any health problems or medical conditions that might preclude participation.
• I will follow instructions given to me by any persons conducting the activity, including
wearing life preservers or similar protective equipment.
• I also know that the activity could be dangerous, and I will take appropriate precautions to
minimize the possibility of injury to others and myself.
I understand that Pinellas County and Sutherland Bayou Bait Shack are relying on these statements in
allowing me to participate in the activity. I also understand that by signing below, I am releasing the
Pinellas County, Sutherland Bayou Bait Shack and their respective officers, employees, and agents from any liability for personal injury or property damage if I, or anyone under my control, is injured or property is damaged, whether before, during, or after participating in the activity, which means, I am agreeing not to sue them if anything happens to me or my property. By signing below, I am also agreeing to indemnify and hold them harmless from and against any claim, damage, loss, cost, expense, or other liability (including, without limitation their attorney’s fees and costs of defense) in the event a claim is made against one or more of them as a result on my participation of the activity.
_____Yes, we are bringing a cell phone, which will be on and accessible on the water.
Home Phone ______
Emergency Contact: ______Phone Number:______
______
Signature Date
______
Signature Date
______
Signature Date
______
Signature Date