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Confirmation
Section 4: DEVICE SUPPLEMENTS - BUNGEE TRAMPOLINE SUPPLEMENT
Do you own a Bungee Trampoline?
Yes
No
Annual Receipts:
Location of Eurobungees:
Eurobungees
How many?
Manufacturer/Model
Manufacturer Year
Trampoline Dimensions
Support Pole Height
Please complete the following for each piece of equipment:
Harnesses
Manufacturer
Size/Model Type
Number on Hand
Age of Oldest One
Replacement Frequency
Date last replaced
Bungee Cords
Manufacturer
Size/Model Type
Number on Hand
Age of Oldest One
Replacement Frequency
Date last replaced
Carabineers
Manufacturer
Size/Model Type
Number on Hand
Age of Oldest One
Replacement Frequency
Date last replaced
More Information
What is the maximum jumping height capacity?
How old is the jumping surface of each trampoline?
Do you always fit harnesses to the size of each person?
Yes
No
Are all attendants trained on manufacturer specifications for fitting harnesses?
Yes
No
Do you always adjust the bungee cords according to manufacturer recommendations for the weight and height of each user?
Yes
No
Are all attendants trained on manufacturer requirements for bungee cord adjustment?
Yes
No
Do you require users to comply with age, weight and height restrictions?
Yes
No
What are the minimum and maximum age requirement for users?
Minimum
Maximum
What are the minimum and maximum weight restrictions for users?
Minimum
Maximum
What are the minimum and maximum height restrictions for users?
Minimum
Maximum
How do you verify weight/height when user size visually appears to be over the limit?
Does your waiver indicate any user restrictions noted by the manufacturer?
Yes
No
Do you always maintain a one to one ratio of attendant supervision for each person on a trampoline?
Yes
No
If not please describe procedure.
Do you always restrict users to one at a time per trampoline?
Yes
No
Is there a barrier or fence around the attraction to prevent pedestrian or observation traffic in the jumping area?
Yes
No
Is access to area around attraction restricted to attendants and one user per attraction?
Yes
No
Are user restrictions, warning and safety signs clearly posted by the entrance to the attraction?
Yes
No
Do you inspect all the equipment daily?
Yes
No
Do you document your inspections with a written checklist and findings?
Yes
No
How long are records of inspections maintained?
Describe the experience of the person(s) in charge of inspecting an supervising use of the bungee jump trampolines.
Is this equipment always attended when set up?
Yes
No
Is this equipment located in one site or moved from site to site?
Do you always set up and take down the equipment if moved from the site?
Yes
No
Do you fully test and inspect the equipment after each set up?
Yes
No
How long do you retain the records of testing and inspecting your set up?
Do all users sign and date a waiver and release document?
Yes
No
Are minors required to have a parent or legal guardian sign the waiver?
Yes
No
Attach Copy of Waiver & Release Document
Do you use a written checklist to document your testing and inspecting after each set up?
Yes
No
Does your waiver require signing party to represent in writing that they are over 18?
Yes
No
Do you require a legibly printed name of the signing party on your waiver?
Yes
No
Is secured padding provided over the trampoline springs and frame perimeter?
Yes
No
Is the flooring beneath and surrounding the perimeter of the attraction padded?
Yes
No
What is the height clearance between the highest point of the attraction and the ceiling?
What is the perimeter clearance maintained around each attraction?
Were all attractions addressed on this supplemental application inspected and found satisfactory by a state or local authority?
Yes
No
Please provide the date of last inspection, testing authority, and any applicable certificate or inspection number.
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