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Certification Class Waiver

Required for All Certification Courses



THE DIVING COURSE YOU ARE ABOUT TO BEGIN IS AN EXCITING AND DEMANDING CHALLENGE!!

This diving course upon completion, will allow you to eventually explore the other three - fourths of our planet that is underwater. To accept the call of this underwater adventure you must be aware of the risks involved in the sport and to study and practice to achieve success.

This course will require heavy physical exertion. You will need to be able to equalize pressure in your ears and sinuses. Your respiratory and circulatory system must be in good health. You should be able to swim in the open ocean. You will need to complete a medical history form and your instructor may require you to be examined by a physician. You will need to read and sign this Statement of Understanding. If you are a minor you will need to have this form and the medical form signed by a parent or guardian.

Skin and Scuba diving are equipment-oriented sports. Some equipment is personal and may need to be purchased.

Other equipment can be rented or will be provided during the course, do not purchase equipment until it has been discussed in class and you know how to evaluate your purchases. 

The cost of an Intro to Scuba or Discovery Scuba Dive is $149 per person for a one-tank dive and $209 per person for a two-tank dive (No certification card issued for these dives). The cost of the Open Water Course is $329 per person (up to 5 students), $800 per person (up to 2 students) and $1500 per person (private one person). This includes all scuba equipment for ocean dives unless arranged otherwise. The cost of a Log Book is $27.60. The cost of the certification card is $50.40 if you qualify as an Open Water Diver. Certification cards may be withheld until payment has been received by the dive shop from the activity center you paid your monies to.

Customer(s) wishing to cancel or reschedule activity must provide 72 hours notice to Maui Diving Scuba & Snorkel Center. Skipping days in class unless scheduled by the Dive Center will result in additional charges to the participant (diver) should you choose to complete the dive class. This would be treated as a private course and the additional charges will reflect such.

All students not following class structure will be charged the single dive rate of $149 each dive (no exceptions). NO REFUNDS WILL BE GIVEN FOR CANCELLATIONS BY CUSTOMER WITH LESS THAN 72 HOURS NOTICE OR WHEN ALTERNATE SITES ARE SELECTED OR FOR ANY OTHER REASON, SUCH AS WEATHER, EAR TROUBLE, ILLNESS OR SEASICKNESS; BEFORE, DURING OR AFTER DIVING! Customer has been informed that a medical form will follow. Failure of completion for reasons on the medical form within 72 hours does not constitute a refund.

BY INITIALING THIS I UNDERSTAND ALL OF THE ABOVE CONTENTS.

May 28, 2022

Important information is included in every open water session. Because diving is built from a few basic steps to more complex concepts, you must attend every session of your training or your training will be incomplete. You will be required to make up any missed sessions at an additional cost to you. Bring paper and pencil to take notes in class and to fill out your logbook after dives. Your logbook and notes will help you study for the test evaluations. You will need to successfully complete a final classroom test and water evaluation in order to be certified.

I understand this is a home study course and performance based. Students will meet at the dive shop each morning unless the instructor requests another location.

Open water sessions will be part of your normal open water training. There will be four open water dives to complete your course, which are required for certification. To help you study and become familiar with the terminology of the sport to gain an understanding of the concepts and laws that govern skin and scuba diving, you will need to have the course eLearning. All of our instructors are affiliated with, and your eLearning will be with PADI.

(PURCHASING AND COMPLETING THE eLEARNING AND LOG BOOK ARE REQUIRED FOR OPEN WATER CERTIFICATION.)

I understand that in undertaking dive training I am incurring obligations for attendance, skill performance and financial responsibility. I understand that diving is a demanding and exciting sport that requires a commitment of time, money, cooperation and practice in order to become certified. I am willing to accept the risks and responsibilities for my own actions and I understand that the instructor must make the final judgment as to my competency.

I understand and agree that any equipment provided to me by the above listed individuals/agencies is to be returned upon my completion of class EACH DAY. Any equipment, which is provided to me and becomes lost or damaged throughout the course, will be paid by the student, at full retail replacement cost. Kama'aina students have up to 3 months to complete dives and test. The Instructor may change this time frame. Failure to complete the course within this time period, will result in the need to pay for another course and must be taken over. By signing this waiver, I understand that I have purchased an activity or service. I understand this contract supersedes all previous contracts and agreements with my credit card company and I personally guarantee payment in cash, or credit card to vendor MAUI DIVING SCUBA & SNORKEL CENTER Activity Centers known or unknown vendors ETC.

Please read carefully, fill in all blanks and agree to each paragraph before signing. 

I hereby affirm that I have been advised and thoroughly informed of the inherent hazards of skin and scuba diving.

I Agree

I further agree that under no circumstance will I make, prosecute or present any claim against those entities identified above for any act, omission or due to their negligence either passive or active relating to such activities or from the ownership, maintenance, use operation or control of any automobile, shop, boat, hotel, vehicle common carrier, or otherwise. It is my intention by signing this document to exempt and release those entities identified above and their agents, servants, contractors and employees from liability for personal injury, property damage, wrongful death and loss of services whether caused by negligence either passive or active or otherwise. By signing this document, I acknowledge that I assume all risk of personal injury, property damage, wrongful death or loss of services upon myself.

I Agree

I further state; I will not fly in an airplane or go to Haleakala Crater (volcano 10, 023ft.) within 12 or 18 hours after my last dive or exceed 1,000 feet in elevation during this scuba diving class. I understand that drinking alcohol directly after diving may cause decompression sickness.

I Agree

I understand that the terms herein are contractual and not a mere recital, and that I have signed this document of my own free act. I also understand by not initialing or signing any part of this waiver will be construed as I am doing so with full intent and knowledge to defraud these contract(s) and can be held responsible for fraud or terminated from this diving program at any time with no refund.

I Agree

Standard Safe Diving Practices Statement of Understanding

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.

This is also a release of your right to sue Maui Diving Scuba & Snorkel Center and its employees, contractors, agents and assigns for personal injuries of wrongful death that may occur during the forthcoming dive activity as a result of the inherent risks associated with scuba diving/snorkeling or as a result of negligence, passive or active. Agree to all Lines 1-11.

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.

I Agree

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.

I Agree

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.

I Agree

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.

I Agree

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.

I Agree

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.

I Agree

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).

I Agree

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.

I Agree

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

I Agree

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

I Agree

11. 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.

I Agree

Liability Release and Assumption of Risk Agreement

I, by this instrument do exempt and release my instructor(s), the facility through which I received my instruction, Maui Diving Scuba & Snorkel Center, PADI and ALL RELATED ENTITIES AS DEFINED OR UNDEFINED, from all liability or responsibility whatsoever for personal injury, property damage or wrongful death however caused. Including but not limited to negligence, whether passive or active and shall include released parties. I have fully informed myself of the contents of this liability release and express assumption of risk by reading it before I signed it on behalf of my heirs and myself. I further acknowledge I will be financially responsible with respect to payment for services rendered by entities. Maui Diving Scuba & Snorkel Center all activity centers unknown but inclusive of payment. I personally guarantee payment by credit card, check, travelers check for activity regardless of locations, weather, ear trouble, seasickness or any other factors, which might arise before, during or after diving. By signing this release. I have purchased an activity or service and understand no refunds will be considered whatsoever. I understand this contract supersedes any and all previous agreements I have with my credit card company.

I understand and agree that PADI Members (“Members”), including Maui Diving Scuba & Snorkel Center 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 Maui Diving Scuba & Snorkel Center and/or the instructors and divemasters associated with the activity.

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 diving trips, as well as 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 trips and 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, Maui Diving Scuba & Snorkel Center #18786 , 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 occurs a result of my participation in this diving trip or 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 diving trip or 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 trip or program including both claims arising during the trip or 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 trip or 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 that I have the authority to do so and that my heirs, assigns, or beneficiaries will be stopped from claiming otherwise because of my representations to the Released Parties.

I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT BY READING IT BEFORE I SIGNED IT ON BEHALF OF MYSELF AND MY HEIRS.

I, BY THIS INSTRUMENT DO EXEMPT AND RELEASE MAUI DIVING SCUBA & SNORKEL CENTER AND ALL RELATED ENTITIES AS DEFINED ABOVE FROM ALL LIABILITY WHATSOEVER FOR PERSONAL INJURY. PROPERTY DAMAGE. WRONGFUL DEATH CAUSED BY NEGLIGENCE. PASSIVE OR ACTIVE. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS INFORMATION AND RELEASE BY READING IT BEFORE I SIGNED IT ON BEHALF OF MYSELF, MY FAMILY, HEIRS, ESTATE. AND/OR ASSIGNS. BY SIGNING THIS RELEASE FORM, I UNDERSTAND THAT I HAVE PURCHASED ACTIVITY OR SERVICE. I UNDERSTAND THIS CONTRACT SUPERSEDES ALL PREVIOUS CONTRACTS AND AGREEMENTS WITH MY CREDIT CARD COMPANY AND I PERSONALLY GUARANTEE PAYMENT, CREDIT CARD. CHECK TO VENDOR.

BY INITIALING THIS I UNDERSTAND ALL OF THE ABOVE CONTENTS.

May 28, 2022



First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
2022 PADI Diver Medical Participant Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by Maui Diving Scuba & Snorkel Center located in the city of Lahaina, state of Hawaii.

Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent or guardian.

Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks. To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. You can download the Diver Medical | Participant Questionnaire form online to take to your physician for a medical evaluation. The form is located at https://www.uhms.org/images/Recreational-Diving-Medical-Screening-System/forms/Diver_Medical_Participant_Questionnaire_10346_EN_English_2022-02-01.pdf

PADI medical form online and page two will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician. The physician providing medical clearance cannot be the student.

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. 

Note to Women: If you are pregnant, or attempting to become pregnant DO NOT DIVE.



Please answer these 10 questions. If you have to answer YES to one of them, please scroll down to the additional questions in the appropriately labeled section.
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes (Go to Box A)
No
2. I am over 45 years of age. *
Yes (Go to Box B)
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 (Go to Box C)
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 (Go to Box D)
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 or developmental disability. *
Yes (Go to Box E)
No
8. I have had back problems, hernia, ulcers, or diabetes. *
Yes (Go to Box F)
No
9. I have had stomach or intestine problems, including recent diarrhea. *
Yes (Go to Box G)
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam). *
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.

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 subsequent questions in the boxes below, please read and agree to the statement above by signing and dating it AND take all three pages of the Diver Medical | Participant Questionnaire form to your physician for a medical evaluation. You can download the Diver Medical | Participant Questionnaire form online. The form is located at https://www.uhms.org/images/Recreational-Diving-Medical-Screening-System/forms/Diver_Medical_Participant_Questionnaire_10346_EN_English_2022-02-01.pdf Participation in a diving course requires your physician's approval. 







Today's Date *

By Entering Your Name here you are digitally signing that you understand the above Participant Statement *
Box A - I Have/Have had:

Only answer these questions if you've said yes to Question 1 above.

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g., stent, pacemaker, neurostimulator) or a pneumothorax (collapsed lung).
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:

Only answer these questions if you said YES to Question 2 above.

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:

Only answer these questions if you said YES to Question 4 above.

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:

Only answer these questions if you said YES to Question 6 above.

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:

Only answer these questions if you said YES to Question 7.

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:

Only answer these questions if you said YES to Question 8.

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:

Only answer these questions if you said YES to Question 9.

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
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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. 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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