Passenger Form

NEOMI CRUISE

PT. BAHARI INDONESIA RAYA
Jalan Kutat Lestari No. 9Y, Sanur Denpasar - Bali - Indonesia
Phone : +62-361-4493418   |   Hotline : +62 813 1234 6176 | +62 821-4783-6655
info@neomicruise.com

PASSENGER’S FORM & LIABILITY RELEASE


Please fill in and return this form together with a copy of your diving certification card via email to: info@neomicruise.com

If you already made this before and want to change it, fill the date of your trip and your email address here : Date Triip :   |   Email :


Neomi Cruise Office
Phone : +62 361 4493418
Hotline : +62 81 353856799

IMPORTANT: All informations must be filled in completely

Diving Trip
Departure Date :
Destinations :


PERSONAL INFORMATION
Title: Mr / Mrs / Ms
Full name
(as it appears on your passport/KTP)
:
Passport/KTP No
(requirement from the port to complete the passenger clearance)
:
Nick name
(name you like to be called whilst on-board)
:
Date of Birth:
Gender:
Male  Female
Nationality:
E-mail address
(requirement from the port to complete the passenger clearance)
:
Telephone:
Mobile phone:
Cabin type:Twin Bed   Double Bed
( * for room 301 double bed only )
(If you are in a group then your group leader will do this for you)
Special Request:
How do you know Neomi Cruise?:


DIVING QUALIFICATION
Qualifying agency (e.g. PADI, SSI, NAUI, BSAC etc):
Qualification level (e.g. Open Water, Advanced, etc):
Number of dives:
Date of last dive:


EQUIPMENT

We recommend each guests to bring their own dive gear but if you need to rent equipment, please inform us long in advance for availability. All prices mentioned are per day in US Dollar or Rupiah at the rate of payment day. You can pay in advance with bank transfer or pay cash onboard (Please tick all required equipment and specific sizes)

Snorkeling Equipment(mask, snorkel, fins) : USD 15.00/diving day
Mask : USD 8.00/diving day
Snorkel : USD 8.00/diving day
FinsS   M   L   XL : USD 8.00/diving day
WetsuitS   M   L   XL : USD 8.00/diving day
Regulator : USD 10.00/diving day
BCDS   M   L   XL : USD 10.00/diving day
Torch & Battery : USD 8.00/diving day
Battery : USD 1.00/diving day
Dive Computer : USD 10.00/diving day
Underwater Camera : USD 20.00/diving day
Tank 15 Liters : USD 10.00/diving day
Nitrox : USD 10.00/dive
Nitrox Package : USD 20.00/diving day

 

EMERGENCY CONTACT INFORMATION
Name:
Relationship:
Telephone:
*Note: We recommend that every passenger must have diving insurance and for those who don't have, the following link is one of the insurance providers that you may choose:

https://apps.dan.org/scuba-dive-insurance/?a=memberinfo



EMBARK
Transfer information on day of embarkation:
From:
Pick-up from: Airport   Hotel
Flight number:
Arrival time / date: /
Name of hotel:
Room Number: (optional) *If you know
Address:

DISEMBARK
Transfer information on day of disembarkation:
To:
Drop off to: Airport   Hotel
Departure time / date: /
Flight number:
Name of Hotel:
Room Number: (optional) *If you know
Address:


HEALTH INFORMATION
(Answer with yes / no plus related information)
Are you medically fit to dive?:
Yes No
Do you take medication?:
Yes No
Do you have allergies?:
Yes No
Do you have dietary restriction?:
Yes No
If yes, what allergies?:
If yes, which medication?:
If yes, which dietary restriction?:

RELEASE OF LIABILITY & ASSUMPTION OF RISK
* Please read this document carefully

Boat – Event – Travel

ASSUMPTION OF RISK, LIABILITY RELEASE & HOLD HARMLESS AGREEMENT
This is a legal contract terminating your rights to file a lawsuit. Read carefully before signing.

Neomi Cruise hosts Activities, including but not limited to snorkeling, freediving, breath-hold diving, scuba diving, technical diving, dive instruction, aquatic life interactions, land and underwater exploration, travel (in air, on land and over water), boating, fishing, lodging, food, beverages and all related activities (herein referred to as “Activities”). These Activities are inherently dangerous and may result in property loss, illness, injury, and death. In consideration of being allowed to participate in the Activities, I HEREBY AGREE TO BE LEGALLY BOUND BY THE TERMS AND CONDITIONS OF THIS ASSUMPTION OF RISK, LIABILITY RELEASE & HOLD HARMLESS AGREEMENT (herein referred to as “Agreement”).

Agreement Parties: I, on behalf of MYSELF, MY FAMILY, HEIRS, ASSIGNS, REPRESENTATIVES & ALL WHO MAY HAVE A CLAIM ON MY BEHALF (hereafter referred to as “me”, “my”, “I” or “Participant”), voluntarily enter into this Agreement with the aforementioned host, including but not limited to their owners, officers, directors, sponsors, agents, insurers, employees, captains, crewmembers, dive professionals, volunteers, boats (whether owned, operated, leased, or chartered), and all other persons and businesses associated with the Activities, whether specifically named or not (hereafter referred to as “Released Parties”).

Participant’s Responsibilities & Assumption of Risks: I understand there are inherent risks of property loss, illness, injury, and death associated with the Activities. I will follow safe practices, maintain awareness and use good judgment set forth in the applicable SSI Responsible Code to reduce the risks, however I know the risk of property loss, illness, injury and death cannot be eliminated. I hereby agree to be solely responsible for my health, safety, and actions. If I choose to scuba dive, I hereby affirm that I am a certified and competent diver or a student under the supervision of a certified scuba instructor. I am solely responsible to verify the function and adequacy of the equipment I use prior to each dive and to monitor my gas supply throughout my dives. I will plan and conduct all dives within my training and ability and return to the dive boat with a minimum of 500psi cylinder pressure. In the event I choose to dive without a dive partner or continue my dive in the absence of a dive partner, I understand and accept the increased risks of solo diving. I understand the Activities will expose me to inherent dangers including but not limited to: panic, drowning, decompression illness, overexpansion injuries, pressure related injuries, breathing gas toxicities, equipment failure, dangerous acts of others, infections, illnesses, allergic reactions, communicable illnesses and diseases, marine life bites and stings, dangerous environmental conditions, and risks associated with boating Activities, including but not limited to transits, boarding, departing, lodging, transfers, entering and exiting the water, that expose me to inherent dangers including but not limited to unexpected movements, slipping, tripping, falling, dangerous environmental conditions, fire, equipment failure, capsize, sinking, grounding, abandonment, collision, dangerous acts of others, being hit by a boat, hazards of the sea. I UNDERSTAND THERE ARE RISKS OF PROPERTY LOSS, ILLNESS, INJURY AND DEATH EVEN WHEN ALL SAFETY MEASURES ARE IN PLACE AND UTILIZED. DESPITE THE RISK OF PROPERTY LOSS, ILLNESS, INJURY AND DEATH, I VOLUNTARILY CHOOSE TO PARTICIPATE IN THE ACTIVITIES AND ASSUME ALL RISKS ASSOCIATED WITH THE ACTIVITIES, WHETHER FORESEEN OR UNFORESEEN, AND WHETHER CREATED OR NOT BY THE RELEASED PARTIES.

Participant’s Condition & Emergency Awareness: I will participate in the Activities within my certification level, experience, skill and abilities. My participation in the Activities is voluntary and if I do not feel well, willing, capable and competent to participate, or if I become aware of an unsafe condition, I will take appropriate action for my safety and/or refrain from participation. I hereby affirm I am physically, medically and mentally fit to participate in the Activities. I will not hold the Released Parties responsible for any condition that results in illness, injury or death to me. I will not possess or consume illegal drugs or medications contraindicated for the Activities. I will not participate in the Activities while under the influence of alcohol or drugs (other than medications prescribed or authorized to me by a physician). I understand the Activities will be conducted at remote locations delaying emergency response, medical care and hyperbaric care. I understand that diving with compressed gases involves inherent risks, including but not limited to, over expansion injuries, decompression injuries, embolism and drowning. Diving injuries may require treatment in a hyperbaric chamber. I understand that these Activities may be conducted at a site that is remote, by time and distance, from a hyperbaric chamber and medical facilities. Despite the inherent risks, I expressly choose to proceed with the Activities in the absence of a nearby hyperbaric chamber and medical facility. I EXPRESSLY ASSUME THESE RISKS AND HEREBY RELEASE THE RELEASED PARTIES FOR FAILURE TO RESCUE OR PROVIDE PROPER EMERGENCY RESPONSE OR MEDICAL CARE. I AUTHORIZE THE RELEASED PARTIES TO PROVIDE FIRST AID AND MEDICAL CARE TO ME IF I BECOME ILL OR INJURED. I AGREE TO BE SOLELY RESPONSIBLE FOR AND PAY ALL EXPENSES ASSOCIATED WITH ANY EMERGENCY RESPONSE AND MEDICAL CARE PROVIDED TO ME, INCLUDING BUT NOT LIMITED TO EMERGENCY OXYGEN, FIRST AID SUPPLIES, EMERGENCY RESPONSE, TRANSPORTATION, FOOD, LODGING, SPECIAL NEEDS, HYPERBARIC TREATMENT AND/OR MEDICAL CARE PRIVIDED BY THE RELEASED PARTIES. I UNDERSTAND THE IMPORTANCE OF, AND MY RESPONSIBILITY TO HAVE, PERSONAL INSURANCE THAT SPECIFICALLY COVERS DIVE AND TRAVEL RELEATED EMERGENCIES AND MEDICAL CARE.

Release of Liability: In consideration of being allowed to participate in the Activities, I HEREBY AGREE TO FOREVER RELEASE THE RELEASED PARTIES FROM ALL LIABILITY ARISING AS A RESULT OF MY PROPERTY LOSS OR DAMAGE, ILLNESS, INJURY AND OR DEATH DUE TO ANY ACT OR FAILURE TO ACT, INCLUDING BUT NOT LIMITED TO NEGLIGENCE OF ANYONE, INCLUDING NEGLIGENCE BY THE RELEASED PARTIES. I SHALL NOT HOLD THE RELEASED PARTIES RESPONSIBLE OR LIABLE FOR DEFECTIVE PRODUCTS OR THE ACTS OF THIRD PARTIES, VENDORS, SUPPLIERS OR CONTRACTORS. I UNDERSTAND THIS IS A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY OF THE RELEASED PARTIES TO THE GREATEST EXTENT ALLOWED BY LAW.

Hold Harmless & Indemnification: I AGREE TO HOLD HARMLESS & INDEMNIFY THE RELEASED PARTIES FROM ALL CLAIMS, CAUSES OF ACTION OR LAWSUITS ARISING FROM MY PARTICIPATION IN THE ACTIVITIES. I HEREBY OBLIGATE MYSELF, AND MY FAMILY OR MY ESTATE, IF I AM DECEASED, TO BE FULLY RESPONSIBLE TO PAY ALL COSTS ASSOCIATED WITH ANY CLAIMS, CAUSES OF ACTION, LAWSUITS OR JUDGMENTS AGAINST THE RELEASED PARTIES AS A RESULT OF MY PARTICIPATION IN THE ACTIVITIES. COSTS INCLUDING DEFENDING AND PAY ALL JUDGMENTS, COURT COSTS, DAMAGES, INVESTIGATION COSTS, ATTORNEY FEES AT ALL LEVELS, INCLUDING PRE-LAWSUIT, TRIAL, MEDIATION, ARBITRATION, APPEAL, AND ALL OTHER EXPENSES INCURRED BY THE RELEASED PARTIES THAT RELATE TO ENFORCEMENT OF THIS AGREEMENT.

I understand and agree the SSI licenses training centers, professionals and their affiliates to use various SSI trademarks and to conduct SSI approved training, but they are not agents, employees or franchisees of SSI, its parent, subsidiary, or affiliated corporations. I further understand SSI training centers, SSI professionals, and their affiliates’ businesses are independent, and are neither owned, operated, or controlled by SSI, and that while SSI establishes standards and materials for SSI training, it is not responsible for, nor does it have the right to control, the operation of the business activities or the day-to-day training and or supervision of Participants by SSI training centers, SSI professionals, their affiliated businesses, and/or their associated staff. I further understand and agree on behalf of myself, that in the event of injury, illness or death during the Activities, I shall not hold SSI liable for the actions, inactions or negligence of the SSI training center, SSI professionals and other affiliated businesses or personnel associated with my participation in the Activities.

Legal Contract, Governing Law & Severability: I understand this Agreement is a contract giving up My legal rights. This Agreement shall be in full legal force from the time I sign it, through the duration of all Activities, and into the future until all claims and legal action against the Released Parties arising as a result of my participation in the Activities are fully resolved. I agree that any legal action arising as a result of my participation in the Activities shall be governed by the Laws of the State in which the Host is located, and that State shall be the exclusive jurisdiction and venue of any legal action. If any portion of this Agreement is found to be unenforceable or invalid, then that portion shall be severed, and the remainder shall continue in full legal force. I agree that any photocopy, fax copy, or electronic completion/signature/ confirmation of this Agreement shall have full legal force as if it were an original document signed by me. I VOLUNTARILY AND FREELY ENTER INTO THIS CONTRACT BASED EXCLUSIVELY ON THE PREPRINTED TERMS OF THIS AGREEMENT WITHOUT MODIFICATION AND WITHOUT RELYING ON ANY OTHER REPRESENTATIONS OR ASSURANCES.

I HAVE FULLY READ, UNDERSTAND AND AGREE TO BE LEGALLY BOUND BY THIS AGREEMENT. I UNDERSTAND THAT BY SIGNING THIS AGREEMENT, I AM GIVING UP LEGAL RIGHTS FOR MYSELF AND ALL OTHERS WHO MAY HAVE A CLAIM ON MY OR THEIR BEHALF AGAINST THE RELEASED PARTIES AS A RESULT OF MY PARTICIPATION IN THE ACTIVITIES.


PARENTAL CONSENT – YOUTH ADDENDUM

ALL PARTICIPANTS UNDER 18 YEARS OF AGE MUST HAVE A PARENT’S SIGNATURE AGREEING THAT THE PARTICIPANT AND PARENTS OF THE PARTICIPANT ARE LEGALLY BOUND BY THIS AGREEMENT.
NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN

READ THIS FORM COMPLETELY AND CAREFULLY, YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN POTENTIALLY DANGEROUS ACTIVITIES. YOU ARE AGREEING THAT, EVEN IF THE RELEASED PARTIES USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THE ACTIVITIES BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITIES WHICH CANNOT BE COMPLETELY AVOIDED OR ELIMINATED. BY SIGNING THIS FORM, YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM THE RELEASED PARTIES IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITIES. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE RELEASED PARTIES HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

I Agree
Participant’s Name:
Dive Certificate Number:#
Date:
2024-04-29
Diver Signature:
If you are under 18yrs
Parent / Guardian Name:
Date:
2024-04-29
Parent / Guardian Signature:
By clicking here, I state that I have read and understood the terms and conditions
I Agree