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Liability and Medical Waiver

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, and instruction related thereto (“Diving Activities”).

I understand that these risks can lead to severe injury and even loss of life.

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 understand that snorkeling, skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during Diving Activities, and that if I am injured as a result of heart attack, stroke, panic, hyperventilation, drowning or any other cause, that I expressly ASSUME THE RISK of said injuries and that I will not seek to hold any other party responsible for the same.

I understand that Diving Activities may be conducted at a site that is remote, either by time or distance or both, from a recompression chamber and competent medical assistance. Despite this, I choose to proceed with these Diving Activities even in the absence of a recompression chamber and competent medical assistance.

I understand that there are hazards and risks associated with travel to and from dive sites (“Dive Travel”), including, but not limited to the possible injury or loss of life as a result of a boating accident

Regardless of the potential hazards and risks associated with Diving Activities and Dive Travel, I wish to proceed and I HEREBY PERSONALLY ASSUME ALL HAZARDS AND RISKS, including possible personal injury, loss of life and/or property damage, arising out of or in connection with Diving Activities and/or Dive Travel, whether foreseen or unforeseen, that may befall me while I am a participate in these activities.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT:

In consideration of being allowed to participate in Diving Activities, Dive Travel, and use the facilities and equipment of the parties listed below, I understand and agree that neither my:

Instructor(s): Brad King, and all additional instructors/staff at Kent Island Scuba and/or Marine Science Foundation 

The facility through which I receive my instruction: Brad King, Kent Island Scuba, Marine Science Foundation, nor their affiliate and subsidiary organizations, nor any of their respective employees, officers, directors, representatives, agents, contractors, volunteers, or assigns (hereinafter collectively referred to as the “Released Parties”)

nor the National Association of Underwater Instructors, Inc., nor their affiliate and subsidiary organizations, nor any of their respective employees, officers, directors, representatives, agents, contractors, volunteers, or assigns (hereinafter collectively referred to as the “Released Parties”) may be held liable or responsible in any way for any injury, death or other damages to me or my property that may occur as a result of my participation in Diving Activities or Dive Travel, or as a result of the negligence of any party, including the Released Parties, whether passive or active, foreseen or unforeseen.

I HEREBY WAIVE AND RELEASE ANY AND ALL CLAIMS OR CAUSES OF ACTION THAT I, MY ESTATE, HEIRS, EXECUTORS OR ASSIGNS MAY HAVE FOR PERSONAL INJURY, PROPERTY DAMAGE OR LOSS OF LIFE BASED UPON NEGLIGENCE, ACTIVE OR PASSIVE WITH THE EXCEPTION OF GROSS NEGLIGENCE, FORESEEN OR UNFORESEEN, WHICH ARISE FROM DIVING ACTIVITIES OR DIVE TRAVEL.

By executing this Agreement, I agree to hold the Released Parties harmless from and against all claims or causes of action for any personal injury, property damage, or loss of life which may occur during Diving Activities or and/or Dive Travel.

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 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. By entering into this Agreement, I am not relying on any oral or written representation or statements made by the Released Parties other than what is set forth in this Agreement.

I agree that this Agreement shall be governed by and interpreted in accordance with the laws of the State of California, United States of America. If any provision, section, subsection, clause or phrase of this Agreement is found to be unenforceable or invalid, that part shall be stricken from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable or invalid part 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 on my behalf or as a result of 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 HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.

The information I have provided about my medical history 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 condition.

Please select who will be participating...
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First Student/Diver Name

First Name*

Last Name*

Phone*
First Student/Diver Date of Birth*
First Student/Diver Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Divers Medical Questionnaire

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

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 tak- ing 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.

If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing.

Divers Medical 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.

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. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

The information I have provided about my medical history 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 condition.

Could you be pregnant, or are you attempting to become pregnant?*
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
Are you over 45 years of age and can answer YES to one or more of the following? • currently smoke a pipe, cigars or cigarettes • have a high cholesterol level • have a family history of heart attack or stroke • are currently receiving medical care • high blood pressure • diabetes mellitus, even if controlled by diet alone*

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?*
Frequent or severe attacks of hayfever or allergy?*
Frequent colds, sinusitis or bronchitis?*
Any form of lung disease?*
Pneumothorax (collapsed lung)?*
Other chest disease or chest surgery?*
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
Epilepsy, seizures, convulsions or take medications to prevent them?*
Recurring complicated migraine headaches or take medications to pre- vent them?*
Blackouts or fainting (full/partial loss of consciousness)?*
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
Dysentery or dehydration requiring medical intervention?*
Any dive accidents or decompression sickness?*
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
Head injury with loss of consciousness in the past five years?*
Recurrent back problems?*
Back or spinal surgery?*
Diabetes?*
Back, arm or leg problems following surgery, injury or fracture?*
High blood pressure or take medicine to control blood pressure?*
Heart disease?*
Heart attack?*
Angina, heart surgery or blood vessel surgery?*
Sinus surgery?*
Ear disease or surgery, hearing loss or problems with balance?*
Recurrent ear problems?*
Bleeding or other blood disorders?*
Hernia?*
Ulcers or ulcer surgery?*
A colostomy or ileostomy?*
Recreational drug use or treatment for, or alcoholism in the past five years?*

The information I have provided about my medical history 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 condition.

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*

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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