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Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
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Directions
Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. Note to women: If you are pregnant, or attempting to become pregnant, do not dive. |
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STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP
If you answered NO to all 10 questions above, a medical evaluation is not required. Skip the remaining lettered sections and sign at the bottom. If you answered YES, please continue to the applicable lettered section(s) below before signing at the bottom.
STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP |
Section A - Complete this section if you answered YES to question 1 aboveI have/have had: |
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Section B - Complete this section if you answered YES to question 2 aboveI am over 45 years of age AND: |
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Section C - Complete this section if you answered YES to question 4 aboveI have/have had: |
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Section D - Complete this section if you answered YES to question 6 aboveI have/have had: |
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Section E - Complete this section if you answered YES to question 7 aboveI have/have had: |
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Section F - Complete this section if you answered YES to question 8 aboveI have/have had: |
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Section G - Complete this section if you answered YES to question 9 aboveI have had: |
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Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions. * If you answered YES to questions 3, 5 or 10 above OR to any of the questions in the applicable lettered sections, take a copy of this form (Participant Questionnaire) and the Physician's Evaluation Form you will receive from Culebra Divers to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.
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