I am starting to carry these with me. I have seen some strips to drop into and I want to be ready. I figured someone here might want to do the same.
Pilot History/Liability Release
Name: _____________________________________ Date of Birth: ____________________
Address: _______________________________ City: __________________ State: __ Zip: _____
Phone:_____________Fax:____________________Email:________________________________
Occupation: ___________________________________Date you began flight training: ________
Date you received license: ______________________________Certificate # ________________________
Date & class of last FAA Medical: __________________Date of Last Biannual Flight Review:____________________
TYPE OF LICENSE:
RATINGS: ___________________________________________________________________
FLYING EXPERIENCE DATA
Total Time ____hours Total Hours Past Year _______hours Total Hours Last 90 Days _____hours
AIRCRAFT TO BE USED
Make & Model___________________________________Tail Number______________________
Owner of Aircraft:___________________________________________________
If any of the following answers are “yes” please give full details.
1.Have you ever been penalized, disciplined or fined for violation of FAR’s? _____________________
2.Have you ever been arrested for any reason? ________________________
3.Have you been cited for DUII? ____________________________
4.Have you ever been treated for substance abuse? ____________________________
I ____________________________________________ affirm that the statements in the Liability Release are true, are made in good faith, and no information has been withheld or suppressed.
IN CONSIDERATION OF my flight(s), I, the undersigned, agree, intending to be legally bound hereby, that as the pilot of my flight(s) and the landowners on which my flight(s) will takeoff and/or land (collectively, with their respective successors, heirs, assigns and insurance companies, all of the foregoing are hereinafter referred to as the “Released Parties”), shall not be liable for my death or injury to my person, or for any loss for damage to my property, caused in any manner whatsoever, whether attributable to the negligence, intentional act or omission of one or more of the aforesaid Released Parties, or for any other reason, occurring during the time that I am in, entering or alighting from an aircraft piloted by __________________________________________________. I do hereby, for myself and my heirs and assigns, waive any right of action against the Released Parties from any and all causes or claims that I may have against one or more of the Released Parties from the beginning of time until these presents. I further agree not to sue on any such cause or claim. I fully acknowledge and understand that there are dangers and risks associated with my flight(s) which might result in my injury or death, and I voluntarily desire to participate in, and assume the risks of, my flight(s). I the undersigned, accept liability for all accident/incident-related damages and all liability not covered by the attached insurance policy for flight operations at the property owned by:
Name:___________________________________________________________________
Address:_________________________________________________________________
City:____________________________State:_____________Zip Code:______________
Revokable at any time by property owner:
Date:______Signature:______________ ______________________________________
Witnessed in the presence of:
_________________________________________________________________________
Printed Name of Witness
_________________________________________________________________________
Signature of Witness