Pilot History/Liability Release

Young Life’s Washington Family Ranch

Date: ____

Date and Time of Arrival__ Date and Time of Departure __

Name: __ Date of Birth: __

Address: __ City: __ State: __ Zip: __

Phone:__Fax:__Email:_ __

Occupation: ___Date you began training: ____

Date you received license: ___Certificate # ____

Date & class of last FAA Medical: __Date of Last Biannual Flight Review:___

TYPE OF LICENSE:

RATINGS: Single Engine Land Multi Engine Land Instrument Instructor Single Engine Sea

Glider Multi Engine Sea Rotor Wing R.W. Instrument

FLYING EXPERIENCE DATA (In aircraft under 12,500 lb. Gross)

Total Time __hours Multi Engine __hours Rotor Wing __hours

Total Hours Past Year __hours Tri-Cycle Gear __hours Sea:Multi Engine __hours

Total Hours Last 90 Days __hours Taildraggers __hours Sea:Single Engine __hours

Retractable Gear __hours

AIRCRAFT TO BE USED FOR WASHINGTON FAMILY RANCH TRIP

Make & Model__Tail Number__Total hours__

Total Hours in a/c by pilot last 90 Days__Total Hours in a/c by pilot last Year__

Owner of Aircraft__

Reason for visit__

Passengers__

If any of the following answers are “yes” please give full details.

1.  Are you flying under a waiver? If YES, give details__

2.  Have you ever been penalized, disciplined or fined for violation of FAR’s? If YES, give details__

I/we affirm that the statements in the application are true to the best of my/our knowledge and belief, are made in good faith, and no information has been withheld or suppressed which would adversely affect my/our pilot rating(s).

I/we 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 Washington Family Ranch. If the aircraft flown is not owned by the pilot, I have permission of the owners to conduct this/these flight operations. I hold the operators of the airport and Young Life harmless for any damages related to the operation of aircraft and its passengers.

You are liable for all liabilities related to operation of aircraft you are flying. You must have insurance policies that will cover you, passengers, plane, and structures on the ground. Please attach a copy of your AVIATION LIABILITY POLICY to this release form.

Date:__Signature:__ (type name for signature)