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

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

 

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

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH DIVING AND RELATED ACTIVITIES

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

I Agree

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT:

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

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

(Instructor/s): All Staff & Instructors

(Facility/ies): Culebra Divers

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

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

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

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

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

Signature Of Participant / 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.


Date: March 26, 2023

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

HEALTH DECLARATION DISCLOSURE - COVID 19

Read this statement prior to signing it. You must complete this additional medical questionnaire to enroll in a diver training program or to participate in any diving activity. If you are a minor, you must have this statement signed by your parent or guardian.

DIVER MEDICAL QUESTIONNAIRE

The purpose of this medical questionnaire is to ensure that you are medically fit to dive. Please answer the following questions with a YES or NO. A positive response means that there may be a preexisting condition that could affect your safety while diving. If any of these items apply to you, you should consult with a physician, preferably a specialist in diving medicine, prior to participating in diving activities.

ADDITIONAL DECLARATIONS / COVID-19

I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by Culebra Divers Culebra Divers staff members, and will take all reasonable preventive steps that may be recommended by Culebra Divers staff members, or any relevant public authority.

I Agree

I WILL accept and observe all instructions by Culebra Divers staff members and intend to abide by all existing regulations required tohelp prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities.

I Agree

I ACKNOWLEDGE and ACCEPT that this declaration will be consideredas my consent to Culebra Divers to retain this declaration and disclose it to any relevant authority or service provider for the purposes of ensuring the safety of any third parties that may come in contact with me prior to, during, and after any diving activity.

I Agree

PLEASE NOTE

COVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalescence before returning to full activities – a process that can take weeks or months depending on symptom severity (1).

MEDICAL RECOMMENDATIONS (2, 3):

Divers who have tested positive for COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.

Divers who have had symptomatic COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a medical professional.

Divers who have been hospitalized with or because of pulmonary symptoms in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a medical professional, with complete pulmonary function testing and an exercise test with peripheral oxygen saturation measurement as well as a high resolution CT scan of the lungs.

Divers who have been hospitalized with or because of cardiac problems in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a medical professional that includes a cardiac evaluation, including echocardiography and an exercisetest (exerciseelectrocardiography).

REFERENCES

(1) Return to Diving Post COVID-19 - Issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA

(2) Diving after COVID-19 pulmonary infection - Position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG)

(3) Recreational and professional diving after the Coronavirus disease (COVID-19) outbreak - Position statement of EUBS & ECHM

Today's Date: March 26, 2023



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
First Participant's Signature*
Second Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Second Participant's Signature*
Third Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Third Participant's Signature*
Fourth Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Fourth Participant's Signature*
Fifth Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Fifth Participant's Signature*
Sixth Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Sixth Participant's Signature*
Seventh Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Seventh Participant's Signature*
Eighth Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Eighth Participant's Signature*
Ninth Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Ninth Participant's Signature*
Tenth Participant's Name

First Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
Tenth Participant's Signature*
Parent or Guardian's Email Address

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

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

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


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

First Name*

Last Name*

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

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

Your information will not be shared or used for any marketing purposes:

Certification Level*

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

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

Dive Accident Insurance Provider (e.g. DAN)
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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