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PO Box 474
4 Calle Pedro Marquez
Culebra, PR 00775
787-742-0803

 

Scuba Tune-Up Liability & Release(Good for 1 year-DO NOT keep filling out waivers if you get a reminder)

 

RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICTIONS OF SIGNING

EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH DIVING AND RELATED ACTIVITIES

I do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with Snorkeling, Skin and/or Scuba diving. I fully understand that these risks can lead to severe injury and even loss of life. I understand that diving operations may be conducted at a site that is remote from a recompression chamber and competent medical assistance. Nevertheless, I choose to proceed even in the absence of a recompression chamber and competent medical assistance. Additionally, I understand that there are also risks associated with dive travel, including, but not limited to the possible injury or loss of life as a result of a dive boat accident, as well as travel to and from dive sites. Despite the potential hazards and dangers associated with the activity of diving, I wish to proceed and I freely accept and expressly assume all risk, dangers and hazards that may arise from diving activities which could result in personal injury, loss of life and property damage to me.  

I Agree

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT:

In consideration of being allowed to participate in Snorkeling, Skin and/or Scuba Diving activities as well as the use of any of the facilities and the use of the equipment of the below listed releasees, I hereby agree as follows:

1. TO WAIVE AND RELEASE ANY AND ALL CLAIMS based upon negligence, active or passive with the exception of intentional, wanton or willful misconduct that I may have in the future against any of the following named persons or entities (hereafter referred to as Releasees): 

(Instructor/s) All Staff & Instructors

(Facility/ies) Culebra Divers

2. To release the releasees, their officers, directors, employees, representatives, agents and volunteers, from liability and responsibility, whatsoever,

for any claims or causes of action that I, my estate, heirs executors or assigns may have for personal injury, property damage or wrongful death arising from Snorkeling, Skin and / or Scuba diving activities whether caused by active or passive negligence of the releasees or otherwise with the exception of gross negligence. By executing this document, I agree to hold the releasees harmless for any injury or loss of life which may occur to me during Snorkeling, Skin and/or Scuba diving activities and/or instruction.

3. By entering into this agreement, I am not relying on any oral or written representation or statements made by the releasees, other than what is set forth in this agreement. I further agree that this Agreement shall be governed by and interpreted in accordance with the laws of the State of California, United States of America.

4. If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

I hereby declare that I am of legal age and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.

I Agree

April 24, 2024

STANDARD SAFE DIVING PRACTICES STATEMENT OF UNDERSTANDING

Please read carefully before signing.

This is a statement in which you are informed of the established safe diving practices for skin and scuba diving. These practices have been compiled for your review and acknowledgement and are intended to increase your comfort and safety in diving. Your signature on this statement is required as proof that you are aware of these safe diving practices. Read and discuss the statement prior to signing it. If you are a minor, this form must also be signed by a parent or guardian.

I understand that as a diver I should:

1. Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and refresh myself on important information.

2. Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which I am experienced, postpone diving or select an alternate site with better conditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave or technical diving unless specifically trained to do so.

3. Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correct fit and function prior to each dive. Have a buoyancy control device, low-pressure buoyancy control inflation system, submersible pres- sure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—which- ever you are trained to use) when scuba diving. Deny use of my equipment to uncertified divers.

4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recog- nize that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed six months.

5. Adhere to the buddy system throughout every dive. Plan dives – including communications, procedures for reuniting in case of separation and emergency procedures – with my buddy.

6. Be proficient in dive planning (dive computer or dive table use). Make all dives no decompression dives and allow a margin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 metres/60 feet per minute. Be a SAFE diver – Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer.

7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving. Carry at least one surface signaling device (such as signal tube, whistle, mirror).

8. Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessive hyperventilation when breath-hold diving. Avoid overexertion while in and underwater and dive within my limitations.

9. Use a boat, float or other surface support station, whenever feasible.

10. Know and obey local dive laws and regulations, including fish and game and dive flag laws.

I have read the above statements and have had any questions answered to my satisfaction. I understand the importance and pur- poses of these established practices. I recognize they are for my own safety and well-being, and that failure to adhere to them can place me in jeopardy when diving. 

*******************************************************************

HEALTH DECLARATION DISCLOSURE

I belive myself to by physically able to participate in this activity (when in doubt, seek medical advice from your primary care physician prior to participating).

I Agree

RECOMMENDATIONS FOR RETURNING TO DIVING AFTER COVID-19 (Updated 2/2022)

The Diver Medical Screen Committee (DMSC), in collaboration with the Divers Alert Network (DAN), the World Recreational Scuba Training Council (WRSTC), the Undersea Hyperbaric Medical Society, and the World Underwater Federation (CMAS) has revised its screening system to focus on symptoms most likely to be problematic for divers, as discussed below. (https://www.daneurope.org/en/-/ftd-after-covid-update),

Depending on the clinical manifestation of COVID-19, divers can be divided into 4 groups:

Group A

  • Asymptomatic, paucisymptomatic (nasal congestion and/or sore throat, in the absence of fever, cough, malaise, headache and/or myalgia) with transitory clinical manifestations.
  • In such cases, returning to diving is not recommended before 7 days after recovery.
  • A medical check-up with your treating doctor is recommended if you do not feel you have regained normal physical and mental capacity.

Group B

  • Mild illness (See Table below) where no hospitalization and/or antiviral, antibiotic, cortisone or heparin treatment has been required.
  • In these cases, we recommend a clinical assessment by the family doctor or a Diving Medicine specialist after 10 days since recovery. The assessment should consider the age of the diver, any condition identified as diving risk factors, vaccination status.

Group C

  • Divers who have presented with moderate illness (See Table below) or have otherwise required hospitalization and/or antiviral, antibiotic, cortisone, or heparin treatment due to SARS-CoV-2 infection.

Group D

  • Divers with severe or critical illness (See Table).

Table (Condition/Stage and Features):

  • Asymptomatic infection
  • Diagnosis of SARS-CoV-2 in the complete absence of symptoms
  • Paucysymptomatic form
  • Presence of symptoms such as nasal congestion and/or sore throat, without fever, cough, malaise, headache and/or myalgia
  • Mild illness
  • Presence of mild symptoms (e.g. fever, cough, loss of taste and smell, malaise, headache, myalgia), without shortness of breath, dyspnea, or abnormal chest imaging
  • Moderate illness
  • SpO2 > or = 94% and clinical or radiological evidence of pneumonia
  • Severe illness
  • SpO2 < 94%, PaO2/FiO2 < 300, respiratory rate > 30/min (in adults), or pulmonary infiltrates > 50%
  • Critical illness
  • Respiratory failure, septic shock, and/or multi-organ failure 



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
A signed copy of this waiver will be sent to the email address you provide.
Upload your proof of certification here (FRONT & BACK please, I need all details) & be ready to present at the shop if requested.
  
Click to customize text box label
Valid file types: JPG, GIF, PNG, and PDF
Emergency Contact

Emergency Contact's Name (NOT on tour with you) *

Emergency Contact's Phone Number *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Sex*
Female
Male

CAUTION

Please be sure to enter your name above exactly as it appears on your certification card!


Date of Tour (If diving/snorkeling multiple days, enter first date. Only one waiver is required per participant and is valid for 1 year) *
I have been on a tour with you before*
No
Yes
Certification Level*

You are responsible for finding your certification information if you do not have it available.  We recommend contacting your training agency immediately to avoid tour delays or extra fees.  Proof of certification is required upon arrival.

Number of dives to date*
When was your last dive*
Less than 6 mos
6 mos - 1 yr
1 yr - 2 yrs
2-5 yrs
5+ (Please make sure you are on the afternoon tour)
Dive Accident Insurance*
No
Yes

Dive Accident Insurance Provider
How did you hear about us?*

Diver Medical Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. (If Yes, Go to Section A)*
No
Yes
2. I am over 45 years of age. (If Yes, Go to Section B)*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. (If Yes, Go to Section C)*
No
Yes
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. (If Yes, Go to Section D)*
No
Yes
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. (If Yes, Go to Section E)*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes. (If Yes, Go to Section F)*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea. (If Yes, Go to Section G)*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

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 sections and sign at the bottom.

If you answered YES, please continue to the applicable lettered section(s) below before signing.

STOP -- STOP -- STOP -- STOP -- STOP -- STOP --STOP

Section A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
No
Yes
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
No
Yes

Section B - I am over 45 years of age AND: 

I currently smoke or inhale nicotine by other means.*
No
Yes
I have a high cholesterol level.*
No
Yes
I have high blood pressure*
No
Yes
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
No
Yes

Section C - I have/have had: 

Sinus surgery within the last 6 months.*
No
Yes
Ear disease or ear surgery, hearing loss, or problems with balance.*
No
Yes
Recurrent sinusitis within the past 12 months.*
No
Yes
Eye surgery within the past 3 months.*
No
Yes

Section D - I have/have had: 

Head injury with loss of consciousness within the past 5 years.*
No
Yes
Persistent neurologic injury or disease.*
No
Yes
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
No
Yes
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
No
Yes
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
No
Yes

Section E - I have/have had: 

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
No
Yes
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
No
Yes
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.*
No
Yes
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
No
Yes

Section F - I have/have had: 

Recurrent back problems in the last 6 months that limit my everyday activity.*
No
Yes
Back or spinal surgery within the last 12 months.*
No
Yes
Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.*
No
Yes
An uncorrected hernia that limits my physical abilities.*
No
Yes
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
No
Yes

Section G - I have had: 

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
No
Yes
Dehydration requiring medical intervention within the last 7 days.*
No
Yes
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
No
Yes
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
No
Yes
Active or uncontrolled ulcerative colitis or Crohn's disease.*
No
Yes
Bariatric surgery within the last 12 months.*
No
Yes

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.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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