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PLEASE

READ COMPLETELY &

FILL IN THE BLANKS

 

 

If you are FLYING WITHIN 18 HOURS of this Tour,

PLEASE ADVISE A STAFF MEMBER before completing waiver

 

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

If you are FLYING WITHIN 18 HOURS of completion of this Tour,

PLEASE ADVISE A STAFF MEMBER before completing waiver

 

 

Today's Date: April 26, 2024

DISCOVER SCUBA DIVING

 

Non-Agency Disclosure and Acknowledgment Agreement I understand and agree that PADI Members (“Members”), including Puerto Rico Diving, Inc. dba Rincon Diving & Snorkeling 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 ofand/or the instructors and divemasters associated with the activity.

Liability Release and Assumption of Risk Agreement I (participant name), Puerto Rico Diving, Inc. dba Rincon Diving & Snorkeling, hereby affirm that I 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; decompression sickness, embolism or other hyperbaric injuries can occur that require treatment in a recompression chamber. I further understand that this program 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 this program in spite of the absence of a recompression chamber or medical facility in proximity to the dive site. The information I have provided about my medical history on the Medical Questionnaire is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions. I understand and agree that neither the dive professionals conducting this program, nor the facility through which this program is offered,  Puerto Rico Diving, Inc. dba Rincon Diving & Snorkeling, nor PADI Americas, Inc., nor its affiliate or subsidiary corporations, nor any of their respective employees, officers, agents 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 program or as a result of the negligence of the Released Parties, whether passive or active. In consideration of being allowed to participate in this program, I hereby personally assume all risks for any harm, injury or damage, whether foreseen or unforeseen, that may befall me whileparticipating in this program, including but not limited to the knowledge development, confined water and/or open water activities. I further release and hold harmless the Discover Scuba Diving program and the Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my participation in this program. I further 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, etc., 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 and Assumption of Risk Agreement, or that I have acquired the written consent of my parent or guardian. I understand that 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 and beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties.

I BY THIS INSTRUMENT DO EXEMPT AND RELEASE THE DIVE PROFESSIONALS CONDUCTING THIS PROGRAM, THE FACILITY THROUGH WHICH THE PROGRAM IS CONDUCTED, AND PADI AMERICAS, INC., AND ALL RELATED ENTITIES AND RELEASED PARTIES 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 OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT AND NON-AGENCY DISCLOSURE ACKNOWLEDGMENT AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS AND AFFIRM THE MEDICAL QUESTIONNAIRE IS ACCURATE.

 

IF Participant is under 18 years of age, This document MUST BE SIGNED BY PARENT OR GUARDIAN OF PARTICIPANT.


 

 

 

 

 

 

Please select who will be diving.
AdultMinor
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First Diver's Name

First Name*

Last Name*

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

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
HOW DID YOU HEAR about us?
Click applicable box(es)
Found location by chance
Tour Review Site (TripAdvisor, Google, Expedia, Yelp, etc)
Saw a sign, flyer, billboard
Social Media (facebook, twitter, instagram, etc)
Internet Search
Word of Mouth referral from friend, family, acquaintance
Witness Information

Please TYPE THE NAME OF A PERSON near you to be your WITNESS *
Medical Information

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 Questionaire 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 a 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. 

Please answer the following questions on your past and 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. Your PADI Professional will supply you with a PADI Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to a physician.

To the participant and parent: Please answer YES or NO to the following items to accurately reflect the participant's  past medical history or present medical condition.

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.

Participant Signature:

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

If you answer YES to questions 3, 5, or 10 OR to any of the questions on page 2 (after obtaining the complete 3-page Diver Medical form from your instructor), please read and agree to the statement by signing and dating it AND take all three pages of this 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. 




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


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

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. 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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