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Please read and understand the following information. Initial the boxes. Fill out completely and sign at the bottom.

I, the undersigned individual hereby acknowledge that I have requested instruction and demonstration in the art of ULTRALIGHT AVIATION from <Your Name or Company> in a TWO-SEAT ULTRALIGHT. This is of my own free will with the intention of attempting to learn how to operate an ULTRALIGHT VEHICLE for sport and personal pleasure. I acknowledge that TWO SEAT ULTRALIGHT flying involves certain inherent risks of personal injury or death because of the fact that the pilots are traveling through the airspace with a certain amount of forward motion, controlled by the laws of gravity, and guiding the vehicle through three dimensions. I realize that , regardless of the quality of instruction I receive and equipment I may be furnished for the purpose of training flights, the risk of personal injury or death is always present, just as it is in other high risk sports such as motorcycle riding, skiing, scuba diving and sky diving. [_____]

I acknowledge the fact that <Your Name or Company> is unwilling to provide me with TWO-SEAT ULTRALIGHT instruction and TWO-SEAT ULTRALIGHT equipment unless I freely acknowledge the risk involved and knowingly release such party from any claims I might otherwise assert on a theory of improper instruction or unsafe or defective TWO-SEAT ULTRALIGHT equipment. I therefore do freely and voluntarily release and discharge such party from any and all claims which I or my heirs or personal representatives might have on account of personal injuries, or death I might suffer while flying in a TWO-SEAT ULTRALIGHT VEHICLES during my course of instruction. [_____]

I am over 18 years of age or have parental permission and execute this document prior to my first flight training session, in consideration of the instruction and training to be given me., [_____]

I likewise acknowledge that my instructor has made no representation or promise that I will be successful in learning the art of ULTRALIGHT AVIATION to the point where I would be a safe and qualified ULTRALIGHT pilot. [_____]

I acknowledge that I understand that TWO-SEAT ULTRALIGHT flights are conducted under an exemption granted by the FAA and that the FAA DOES NOT establish certification standards for powered TWO-SEAT ULTRALIGHT vehicles, pilots, and instructors. I have been notified that <Your Name or Company>'s TWO-SEAT ULTRALIGHT maintenance personnel are NOT REQUIRED and DO NOT HAVE and FAA Airframe or Power plant license. [_____]

In witness thereof I have executed this agreement on this _____day of ______________ 19_____.

Name: _____________________________


Signature: ________________________ Parent Signature if student is a minor: ______________________

Address: __________________________

City: _________________________State: ______________Zip: ____________ Phone (_____)_________

Age: _____ Weight: ______ Social Security #__________________ Witnessed: _____________________