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Diver Development Program Student Information

This form gathers information required for all divers in all courses. 

First Participant(s) Name

First Name*

Middle Name

Last Name*

Phone*
First Participant(s) Date of Birth*
First Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
First Participant(s) Signature*
Second Participant(s) Name

First Name*

Middle Name

Last Name*
Second Participant(s) Date of Birth*
Second Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Third Participant(s) Name

First Name*

Middle Name

Last Name*
Third Participant(s) Date of Birth*
Third Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Fourth Participant(s) Name

First Name*

Middle Name

Last Name*
Fourth Participant(s) Date of Birth*
Fourth Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Fifth Participant(s) Name

First Name*

Middle Name

Last Name*
Fifth Participant(s) Date of Birth*
Fifth Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Sixth Participant(s) Name

First Name*

Middle Name

Last Name*
Sixth Participant(s) Date of Birth*
Sixth Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Seventh Participant(s) Name

First Name*

Middle Name

Last Name*
Seventh Participant(s) Date of Birth*
Seventh Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Eighth Participant(s) Name

First Name*

Middle Name

Last Name*
Eighth Participant(s) Date of Birth*
Eighth Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Ninth Participant(s) Name

First Name*

Middle Name

Last Name*
Ninth Participant(s) Date of Birth*
Ninth Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Tenth Participant(s) Name

First Name*

Middle Name

Last Name*
Tenth Participant(s) Date of Birth*
Tenth Participant(s) Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

Weight *
Participant(s) Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian 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*
Diver's Insurance - Please provide your carrier and policy number if applicable.

Please enter the company name and policy number.
Program Selection
Please select the course or experience you are participating in.*

Description of the "Other" course selected.

Your highest certification level. If enrolling in Discover Scuba Diving Experience or Open Water Diver, please leave blank.
Where are you planning on completing your check out dives?*
How did you hear about Tri-City Scuba Centre?*

How you heard about us - "Other"
ACKNOWLEDGEMENT: This form is valid for 1 year from the date of completion as marked on the document. You must also take the course within 12 months of signing up or the fees may not be reimbursed. If your medical condition changes such that you would have to answer a YES on the medical form, you are required to complete a new form and obtain your physician's approval prior to any in-water activity. I understand and agree to the class cancellation policy, namely that if I cancel my participation within 1 week of the start of the class that no refund will be given. Cancellations or reschedule requests made less than 7 business days prior to start date, will be assessed a $75 fee that will be paid prior to taking the rescheduled class.*
Diver Medical ' Participant Questionnaire

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

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving.

Note to women: If you are pregnant, or attempting to become pregnant, do not dive.
I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
No
Yes*. Go to Box A
I am over 45 years of age.*
No
Yes*. Go to Box B
I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitnessor health reasons within the past 12 months.*
No
Yes
I have had problems with my eyes, ears, or nasal passages/sinuses.*
No
Yes*. Go to Box C
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer frompersistent neurologic injury or disease.*
No
Yes*. Go to Box D
I am currently undergoing treatment (or have required treatment within the last five years) for psychologicalproblems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosedwith a learning disability.*
No
Yes*. Go to Box E
I have had back problems, hernia, ulcers, or diabetes.*
No
Yes*. Go to Box F
I have had stomach or intestine problems, including recent diarrhea.*
No
Yes*. Go to Box G
I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
No
Yes

Participant Signature

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. My signature on this document serves as agreement to this statement.

Acknowledgement of the Participant Statement*

Participant Name *

Birthdate (dd/mm/yyyy)

*If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree tothe statement above by signing and dating it AND take all three pages of this form (Participant Questionnaireand the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.

Diver Medical ' Participant Questionnaire Continued


Box A -  I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
No
Yes*
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
No
Yes*
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
No
Yes*
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysem*
No
Yes*
A diagnosis of COVID-19.*
No
Yes*

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

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

Box C - I have/have had:

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

Box D - I have/have had: 

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

Box E - I have/have had: 

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

Box F - I have/have had:

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

Box G - I have had:

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

*Physician's medical evaluation required (see page 1).


Diver Medical ' Physician's Evaluation Form
Please print, have physician complete and bring signed original to Tri-City Scuba Centre)


Participant Name

Birthdate (dd/mm/yyyy)

The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba diving or freediving training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas relevant to your patient as part of your evaluation.

Evaluation Result

(    )  Approved - I find no conditions that I consider incompatible with recreational scuba diving or freediving.

(    ) Not approved - I find conditions that I consider incompatible with recreational scuba diving or freediv




Physican's Signature



Date (dd/mm/yyyy)



Physician's Name (Print)



Specialty


Clinic/Hospital

Address

Phone

Email

Physician/Clinic Stamp (optional)









Created by the Diver Medical Screen Committee (https://www.uhms.org/resources/recreational-diving-medical-screening-system.html) in association with the following bodies:

The Undersea & Hyperbaric Medical Society
DAN (US)
DAN Europe
Hyperbaric Medicine Division, University of California, San Diego



10346
Revised 9July 2020

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.

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.

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 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. Deny use of my equipment to uncertified divers. Always have a buoyancy control device and submersible pressure gauge when scuba diving. Recognize the desirability of an alternate air source and a low-pressure buoyancy control inflation system.

4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. 

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-table usage. Make all dives no-decompression dives and allow a margin of safety. Have a means to monitor depth and time under water. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 metres/60 feet per minute.

7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while under water. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving.

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 under water and dive within my limitations.

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

10. Know and obey local diving laws and regulations, including fish-and-game and dive-flag laws. I have read the above statements and have had any questions answered to my satisfaction. I understand the importance and 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.

Acknowledgement of the Standard Safe Diving Practices Statement of Understanding*
Release of Liability/Assumption of Risk/Release for Media Recording/Non-agency Acknowledgement Form GENERAL TRAINING

Please read carefully

Release for Media Recording

I, the undersigned, do hereby consent and agree that Tri-City Scuba Centre Inc., its employees, or agents have the right to take photographs, videos, or digital recordings of me beginning on date listed below until revoked in writing by the undersigned.
And to use these in any and all media, now or hereafter known, exclusively for the purpose of event promotion. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. 
I do hereby release to Tri-City Scuba Centre Inc., its and agents and employees all right to exhibit this work in print and electronic form publicly and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.
I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.
I also understand that Tri-City Scuba Centre Inc. is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result. 
I represent that I am at least 18 years of age, have read and understand the foregoing statement and am competent to execute this agreement.

Non-Agency Disclosure and Acknowledgment Agreement

I understand and agree that PADI Members ("Members"), including Tri-City Scuba Centre 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 Tri-City Scuba Centre Inc. and/or the instructors and divemasters associated with the activity.

Liability Release and Assumption of Risk Agreement

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 Professional Staff st Tri-City Scuba Centre, the facility through which I receive my instruction, Tri-City Scuba Centre Inc., 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, THE PROFESSIONAL STAFF AT TRI-CITY SCUBA CENTRE, THE FACILITY THROUGH WHICH I RECEIVE MY INSTRUCTION, TRI-CITY SCUBA CENTRE INC., 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.

Acknowledgement of Release of Liability/Assumption of Risk/Non-agency Acknowledgement Form GENERAL TRAINING*
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 Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian Date of Birth*
Parent or Guardian Unisex T-Shirt Size

Unisex T-Shirt Size *

Shoe Size *
Shoe Size*
Male
Female

Height *

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


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