Galapagos Application

GENERAL INFORMATION
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Gender*
- Male
- Female
- Non-Binary
- Prefer Not to Say
Date of birth*
Month
Day
Year
Age on Event Date*
Profession*
Select all that apply in regards to your work situation:*
- Employed/Self-Employed
- Student
- Retired
- Other

EMERGENCY CONTACT & MEDICAL
Emergency Contact #1 Name*
First Last
Relationship*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact #2 Name*
First Last
Relationship*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physician Name*
First Last
Physician Phone*
Physician Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you take any prescription medicines?*
- Yes
- No
If Yes, which prescription medicine(s)?

SWIM & FITNESS INFORMATION
List any sports you currently practice (regularly)*
Have you done long distance or extreme swims?*
- Yes
- No
If Yes, please list Swim Name, Location & Distance
Optional
Do you currently participate in a master swim program?*
- Yes
- No
How would you describe your open water swim ability?*
- New/Novice
- Intermediate
- Advanced
How fast can you swim a mile (2k) in open water or in the pool?*
In minutes or hours
Weekly average pool or open water swimming distance*
Yards/Meters or Miles/Kilometers

INTERNATIONAL INFORMATION
How many companions will travel with you for this swim?*
Your travel companions include*
- Spouse/Partner
- Friends
- Relatives
- Parents
- Guardians
- Team
- Pacer
Your passport number*
Passport issuing country*
Passport expiry date*
Month
Day
Year
Italian Embassy/Consulate in Your Home City*
Address of the Italian Embassy/Consulate where you live.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Phone number of the Italian Embassy/Consulate (addressed above).
Embassy/Consulate of Your Country in Italy*
This address is the embassy/consulate of your home country in Italy.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Phone number of the your home country's Embassy/Consulate (addressed above).

WAIVER & DISCLAIMER AGREEMENTS
This is a statement in which you are informed of some potential risks involved in open water swimming and of the conduct required of you during the long distance open water training program.*
Your agreement to this statement is required for you in order to participate in our open water swim training program offered by Water World Swim, LLC, located in the City of San Francisco, California, USA, Valparaiso, Punta Arenas, Tierra del Fuego , Chile, Italy, and UK.

Your agreement indicates that you understand and accept the following:

ASSUMPTION OF THE RISKS OF COLD WATERS SWIMMING: Swimming in cold waters is inherently dangerous. There have been swimmers that have died due to long exposure to cold water and suffered hypothermia. Also some swimmers swimming in rough open waters in different parts of the world have found obstacles or encounters with wild marine animals that in some instances have attacked swimmers. Swimmers have been injured by objects in the water, both floating and fixed. There may be health hazards associated with pollution and currents, often more powerful than the strongest swimmer, are unpredictable and could swept swimmers off course.

OPEN WATERS IN SOME REGIONS OF THE WORLD ARE EXTREMELY COLD. Temperatures typically range between 40 and 50 degrees Fahrenheit (4.5 C-10 C) . Swift currents and cold water have precipitated drowning, heart attacks and hypothermia. These are just some of the hazards and dangers associated with open water swimming.

I UNDERSTAND AND ASSUME ALL RISKS ASSOCIATED WITH SWIMMING IN OPEN AND COLD WATERS WAIVER AND RELEASE OF WWS: On behalf of my heirs, assignees, personal representative, and next of kin, I hereby release and hold harmless Water World Swim, LLC Organization, its officers, members, officials, agents and employees and other participants, with respect to all injury, disability, death, or loss, injury or damage to me or my property, whether arising from the negligence of Water World Swim, LLC, its members or officers, or otherwise. By signing this waiver and release, I certify that I understand that I cannot sue any person, instructor or coaches or those who act on behalf of the Open Water World Swim, LLC organization or those who may have authority over the company, and no one else can sue on my behalf.
- I agree to the Waiver and Release of Water World Swim, LLC and hereby allow my digital agreement to act in place of my signature.

Galapagos

Step 1 of 5

GENERAL INFORMATION

EMERGENCY CONTACT & MEDICAL

SWIM & FITNESS INFORMATION

INTERNATIONAL INFORMATION

WAIVER & DISCLAIMER AGREEMENTS