Loading...

Non-Agency Disclosure and Acknowledgment Agreement

In European Union and European Free Trade Association countries use alternative form. Please read carefully and fill in all blanks before signing.

I understand and agree that PADI Members (“Members”), including Vancouver Diving Locker and/or any individual PADI Instructors and Divemasters associated with the program in which I am participating, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of PADI Americas, Inc, or its parent, subsidiary and affiliated corporations (“PADI”). I further understand that Member business activities are independent, and are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver training programs, it is not responsible for, nor does it have the right to control, the operation of the Members’ business activities and the day-to day conduct of PADI programs and supervision of divers by the Members or their associated staff. I further understand and agree on behalf of myself, my heirs and my estate that in the event of an injury or death during this activity, neither I nor my estate shall seek to hold PADI liable for the actions, inactions or negligence of Vancouver Diving Locker and/or the instructors and divemasters associated with the activity.


Liability Release and Assumption of Risk Agreement

In European Union and European Free Trade Association countries use alternative form.


Please read carefully and fill in all blanks before signing.

I hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death.

I understand that diving with compressed air involves certain inherent risks; including but not limited to decompression sickness, embolism or other hyperbaric/air expansion injury that require treatment in a recompression chamber. I further understand that the open water diving trips which are necessary for training and for certification may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site.

I understand and agree that neither my instructor(s), the facility through which I receive my instruction, Vancouver Diving Locker nor PADI Americas, Inc., nor its affiliate and subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns (hereinafter referred to as “Released Parties”) may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occur as a result of my participation in this diving program or as a result of the negligence of any party, including the Released Parties, whether passive or active.

In consideration of being allowed to participate in this course (and optional Adventure Dive), hereinafter referred to as “program,” I hereby personally assume all risks of this program, whether foreseen or unforeseen, that may befall me while I am a participant in this program including, but not limited to, the academics, confined water and/or open water activities.

I further release, exempt and hold harmless said program and Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my enrollment and participation in this program including both claims arising during the program or after I receive my certification.

I also understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this program, and that if I am injured as a result of heart attack, panic, hyperventilation, drowning or any other cause, that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same.

I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. I understand the terms herein are contractual and not a mere recital, and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid, that provision shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable provision had never been contained herein.

I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns, or beneficiaries may have to sue the Released Parties resulting from my death. I further represent I have the authority to do so and that my heirs, assigns, or beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties. I BY THIS INSTRUMENT AGREE TO EXEMPT AND RELEASE MY INSTRUCTORS, VANCOUVER DIVING LOCKER, THE FACILITY THROUGH WHICH I RECEIVE MY INSTRUCTION, AND PADI AMERICAS, INC., AND ALL RELATED ENTITIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, INCLUDING, BUT NOT LIMITED TO, THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE.


I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLDGEMENT AGREEMENT AND LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS.


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 pressure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—whichever 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. Recognize 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 understand the importance and purposes 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. 



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.

Diving Medical Guidance to the Physician

These guidelines are typically used by physicians who have been approached by an individual wishing to take part in recreational scuba diving or freediving. They will usually have completed a WRSTC Diver Medical Participant Questionnaire.

Recreational scuba diving and freediving (hereafter "diving") is performed safely by many people. The risks associated with diving may be increased by certain physical conditions, and the relationship to diving may not be readily appreciated by candidates. Thus, it is important to screen divers for such conditions.

A physical examination for diving focuses on conditions that may put a diver at increased risk for decompression sickness, pulmonary overin!ation with subsequent arterial gas embolization, and other conditions such as loss of consciousness, which could lead to drowning. Additionally, divers must be able to withstand some degree of thermal stress, the physiological effects of immersion, and have suf"cient physical and mental reserves to deal with normal diving and possible emergencies.

The history, review of systems, and physical examination should include as a minimum the points listed below. The list of conditions that might adversely affect the diver is not exhaustive, but contains the most commonly encountered medical problems. The brief introductions serve as an alert to the nature of the risk posed.

The potential diver and his or her physician must weigh the bene"ts to be had by diving against an increased risk of injury or death due to the individual’s medical condition. As with any recreational activity, there are limited data for diving with which to calculate the mathematical probability of injury. Experience and physiological principles only permit a qualitative assessment of relative risk.

For the purposes of this document, Severe Risk implies that an individual is believed to be at substantially elevated risk of injury compared with the general population. The consultants involved in drafting this document would generally discourage a candidate with such medical problems from diving. Relative Risk refers to a moderate increase in risk, which in some instances may be acceptable. To make a decision as to whether diving is contraindicated for this category of medical problems, physicians must base their judgment on an assessment of the individual candidate. Temporary Risk refers to medical problems which may preclude diving but are temporary in nature, allowing the individual to dive after they have resolved.

Following many of the sections is a short list of references that give more information on the topic. The lists are not exhaustive, but examples that may be of particular relevance.

Diagnostic studies and specialty consultations should be obtained as indicated to determine the candidate’s status. A list of references is included to aid in clarifying issues that arise. 


Today's date: May 9, 2024

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

Parent or Guardian's Email Address

Email*

Confirm Email*
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*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

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, blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g. stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

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

Box D - I have/have had:

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

Box E - I have/have had:

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

Box F - I have/have had:

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

Box G - I have had:

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

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it AND request the physical form from our website or dive base take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.


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.

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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!