Loading...

Elite Divers International

Playa Del Carmen
Mexico

General Liability Release and Express Assumption of Risk

For Guided Scuba Tours for Certified Divers

Please read carefully, fill in all blanks and initial each paragraph before signing at bottom.

I hereby affirm that I have been advised and thoroughly informed of the inherent hazards of scuba diving activities and participation in a guided tour as a diver.


 

Further, I understand that diving with compressed air, oxygen enriched air (Nitrox), and trimix supplied by standard open circuit scuba or with semi-closed circuit or closed circuit rebreathers involves certain inherent risks including decompression sickness, embolism, oxygen toxicity, inert gas narcosis, hypoxia, hypercapnia, marine life injuries or other barotrauma or hyperbaric injuries. Such injuries can occur that require treatment in a recompression chamber or medical facility. I further understand that dive activities can be at remote sites, and isolated by time and distance, from such a recompression chamber or medical facility. I still choose to proceed with such dives in spite of the absence of a recompression chamber in proximity to the dive site.


 

I understand and agree that neither the instructor/guide, Arthur NGUYEN-KIM / Anne-Laure HUYNH / Mark Michael EHLICH / Carlo ORSACCHINI / Shawn MURPHY / Eduardo RODRIGUEZ, nor any of the respective employees, officers, agents or assigns of ELITE DIVERS / XIBALBA TRAVEL SERVICES, (hereinafter referred to as "Released Parties") may be held liable or responsible in any way for any injury, death, or other damages to me or my family, heirs, or assigns that may occur as a result of my participation in this diving activity 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 activity I hereby personally assume all risks in connection with said trip, for any harm, injury, or damage that may befall me while I am a diving participant including all risks connected therewith, whether foreseen or unforeseen.


 

I further agree to save, defend, indemnify, and hold harmless said Released Parties from any claim or lawsuit by me, anyone purporting to act on my behalf, my family, estate, heirs or assigns, arising directly or indirectly out of my participation and diving activities including claims arising during this activity even if such claims may be groundless, false or fraudulent.


 

I also understand that diving activities are physically strenuous and that I will be exerting myself during this diving trip and that if I am injured as a result of heart attack, panic, hyperventilation, oxygen toxicity, inert gas narcosis, drowning, etc. that I expressly assume the risk of said injuries and that I will not hold the above listed individuals or companies responsible for the same, and I agree to defend, indemnify, and hold harmless said Released Parties for any such injuries incurred by me.


 

I understand that these activities may place me deeper than I am able to safely execute a free ascent (without breathing gas)from.


 

I understand that I may be required to furnish some of my own equipment and that I am responsible for its operating condition and maintenance.


 

I understand that I may be supplied with certain items of scuba equipment and that I am responsible for reviewing its proper function and operating condition prior to using it. 


 

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 am aware of the required certification level and/or experience necessary and recommended to enroll in this diving activity and I stipulate that I meet requirements for prior certification or equivalent experience.


 

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. Further that I understand and agree that, in the event that one or more of the provisions of this agreement, for any reason, is held by a court of competent jurisdiction to be invalid or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and this agreement shall be construed as if such invalid, illegal or unenforceable provision or provisions had never been contained herein.


 

IT IS THE INTENTION OF PARTICIPANT BY THIS INSTRUMENT TO EXEMPT AND RELEASE MY INSTRUCTORS DIVEMASTER/GUIDE, Arthur NGUYEN-KIM / Anne-Laure HUYNH / Mark Michael EHLICH / Carlo ORSACCHINI / Shawn MURPHY / Eduardo RODRIGUEZ, THE BUSINESS, ELITE DIVERS INTL. / XIBALBA TRAVEL SERVICES, AND ALL OTHER RELATED ENTITIES AND RELEASED PARTIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, OR ARISING OUT OF, DIRECTLY OR INDIRECTLY, 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 EXPRESS ASSUMPTION OF RISK BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF AND MY HEIRS.

 

No alterations, changes, omissions or revisions may be made.


Medical Statement

Participant Record (Confidential Information)

Please Read Carefully Before Signing

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 Arthur NGUYEN-KIM / Anne-Laure HUYNH / Mark Michael EHLICH / Carlo ORSACCHINI / Shawn MURPHY / Eduardo RODRIGUEZ and Elite Divers International / Xibalba Travel Services SA DE CV located in the city of Playa Del Carmen state/provice of QR.

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.

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

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.













First Participant's Name

First Name*

Middle Name

Last Name*

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Third Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Fourth Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Fifth Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Sixth Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Seventh Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Eighth Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Ninth Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
Tenth Participant's Name

First Name*

Middle Name

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
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's Email Address

Email*

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

Middle Name

Last Name*

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

I further state that I am already a qualified and certified scuba diver from the following training agencies:


Training Agency

Level of Training

I have been a certified diver since the following date


Date

Total number of diving years

Total number of dives

Maximum diving depth in feet

Medical History

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.

Could you be pregnant, or are you attempting to become pregnant?*
No
Yes
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
No
Yes

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

No
Yes

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

Asthma, or wheezing with breathing, or wheezing with exercise?*
No
Yes
Frequent or severe attacks of hayfever or allergy?*
No
Yes
Frequent colds, sinusitis or bronchitis?*
No
Yes
Any form of lung disease?*
No
Yes
Pneumothorax (collapsed lung)?*
No
Yes
Other chest disease or chest surgery?*
No
Yes
Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?*
No
Yes
Click to customize question*
No
Yes
Epilepsy, seizures, convulsions or take medications to prevent them?*
No
Yes
Recurring complicated migraine headaches or take medications to prevent them?*
No
Yes
Blackouts or fainting (full/partial loss of consciousness)?*
No
Yes
Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?*
No
Yes
Dysentery or dehydration requiring medical intervention?*
No
Yes
Any dive accidents or decompression sickness?*
No
Yes
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
No
Yes
Head injury with loss of consciousness in the past five years?*
No
Yes
Recurrent back problems?*
No
Yes
Back or spinal surgery?*
No
Yes
Diabetes?*
No
Yes
Back, arm or leg problems following surgery, injury or fracture?*
No
Yes
High blood pressure or take medicine to control blood pressure?*
No
Yes
Heart disease?*
No
Yes
Angina, heart surgery or blood vessel surgery?*
No
Yes
Heart attack?*
No
Yes
Sinus surgery?*
No
Yes
Ear disease or surgery, hearing loss or problems with balance?*
No
Yes
Recurrent ear problems?*
No
Yes
Bleeding or other blood disorders?*
No
Yes
Hernia?*
No
Yes
Ulcers or ulcer surgery ?*
No
Yes
A colostomy or ileostomy?*
No
Yes
Recreational drug use or treatment for, or alcoholism in the past five years?*
No
Yes

Physician Information


Name

Clinic/Hospital

Address

Date of last physical examination

Name of examiner

Clinic/Hospital

Address

Phone

Email
Were you ever required to have a physical for diving?*
No
Yes

If so, when?
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!