Adreno Dive Trip Booking Form

ADRENO SCUBA DIVE TRIP BOOKING FORM

PARTICIPANT ACKNOWLEDGEMENT OBLIGATIONS

Each person participating in this activity has obligations under the Workplace Health and Safety Queensland (WHSQ) legislation to assist Adreno staff in making this a safe trip/program and to reduce the possibility of injury or accident. Your assistance is required in the following:

1. Listen carefully and understand the briefings, directions and respect the advice of those supervising and running the activity
2. Participate in head count procedures by signing the log sheet immediately on return to the boat. Divers are also required to report accurate details of their maximum depth, bottom time ad remaining air pressure.
3. Comply with WHS Queensland Recreational Diving Code of Practice: all certified divers engaging in recreational diving must carry (by law) the listed equipment items below. Your signature on this page confirms that you possess these items or have hired them from Adreno.

Safety sausage
Regulator fitted with an alternate air source and SPG
Must carry a snorkel at all time – fitted or in your BCD
BCD with a low-pressure inflator hose
A whistle
A dive computer (sharing with a dive buddy is not permitted)
A wetsuit that is appropriate for the dive conditions

4. Make all dives no-decompression dives. Certified divers not carrying a dive computer are required to carry a bottom timer & a depth gauge and be proficient in dive table usage, allowing a margin of safety. Divers using a computer are recommended to not dive within 10 minutes of your no-deco limits unless conducting SSI XR training or have a pre-approved dive plan. If decompression limits are exceeded, upon surfacing the diver must remain out of the water for a minimum of 6 hours before entering the water for another dive.
5. Adhere to the buddy system throughout every dive unless certified as a self-reliant/solo diver.
6. Mandatory safety stop after each dive for 5 minutes at 5 metres.
7. Plan your dive and dive your plan. Dive time and depth plans must not be exceeded. A maximum dive time of 50 minutes is from surface to surface and includes your safety stop on every dive.
8. Watch your air consumption and return to the boat with a minimum of 50 bar left in your tank.
9. Dive to your level or training and experience
10. Be a SAFE Diver – Slowly Ascend From Every Dive
11. Ask Questions – If you are unsure about anything, please ask staff.

Type Signature

Draw Signature

Click to Sign

Date: April 27, 2024

BOATING, SNORKELLING & SCUBA DIVING LIABILITY RELEASE & ASSUMPTION OF RISK – BINDING AGREEMENT VALID TODAY AND ALL FUTURE DATES

I understand that the psurpose of signing this document is to exempt and release Adreno, SSI (Scuba Schools International), PADI (Professional Association of Diving Instructors), it’s affiliate or subsidiary corporations, their owners, employees, contractors, agents, and associated personnel, and their boats (whether owned, operated, leased or chartered), hereinafter referred to as “released parties”, and to hold these entities harmless from any and all liabilities arising as a consequence of the following, or any other acts or omissions on their part, including but not limited to negligence of any type. This agreement is intended to be valid and binding today and on all future dates.

I understand and accept that there are inherent risks involved with snorkelling, scuba diving and boating, including but not limited to heart attack, panic, hyperventilation, drowning, air expansion, decompression sickness, equipment failure whether on rental equipment or your own personal gear, perils of the sea, harm caused by marine creatures, being cut or struck by a vessel while in the water, acts of fellow participants, entering and exiting the water, boarding and disembarking the vessel and activities that take place on the dock and I hereby assume such risks. I declare that I am in a good mental and physical condition and that I am not under the influence of alcohol, nor am I under the influence of any drugs that are contradictory for the undertaken activity. I will execute an updated medical examination if and when required.

I fully understand that the involved boat has limited medical facilities and that in the event of illness or injury appropriate medical care must be summoned by radio and treatment will be delayed until I can be transported to a proper medical facility. I agree in advance to these conditions. The participating dive store and/or boat have made no representation to me, implied or otherwise that they or their crew can or will perform safe rescues or render first aid. In the event that I show signs of distress or call for aid, I would like assistance and will not hold the released parties, their crew, dive boats or passengers responsible for their actions in attempting the performance of rescue or first aid.

I will inspect all of my rented and personally owned equipment prior to commencing the activity. I will not hold the released parties responsible for my failure to inspect any equipment prior to snorkelling or diving, including checking both quality and quantity of air in any scuba tank(s).

I also agree to pay any costs of repair of replacement if the rented equipment should be lost or returned damaged, including flooding of the regulator due to the dust cap not being effectively secure. For the purpose of payment, the renter gives us permission to charge the credit card that has been listed for payment.

I recognise & acknowledge that Adreno is neither a common carrier not in the business of providing transportation services to the public. I further recognise and acknowledge that there are certain risks of physical injury to vehicle passengers, and I voluntarily agree to assume the full risk of any injuries, damages or loss, regardless of severity that I may sustain as a result of participating in any and all activities connected with or associated with receiving transportation services, including, but not limited to, injuries, damages or loss arising out of negligence operation or supervision to the vehicle. I further agree to waive and relinquish all claims I may have (or accrue to me) against Adreno, including its respective officials, agents, volunteers and employees (hereinafter collectively referred to as “Party”). I agree to wear a seatbelt and to remain seated in the vehicle whenever the vehicle is under operation or when I am instructed to do so. I also agree to not create any distractions to the operator of the vehicle.

IT IS MY INTENTION BY THIS INSTRUMENT TO GIVE UP MY RIGHT TO SUE ALL PERSONS OR ENTITIES REFERRED TO HEREIN, whether specifically named or not, and it is also my intention to exempt and release all released parties and to hold these entities harmless from any and all liability for personal injury, property damage/loss or gross negligence and I assume all but not limited to the maintenance of the equipment or organisation of this activity. I give Adreno and its agents acting on behalf and/or for Adreno full permission to use images taken of me, I give full permission for Adreno to reproduce, alter, use and reuse any image, picture or reproduction for all media.

I HAVE CAREFULLY READ THIS CONTRACT IN ITS ENTIRETY, fully understand its contents, my participation in this activity is entirely at my own risk and agree to the terms and conditions of this contract on behalf of myself, my heirs, and my personal representatives. I have read and understand the participant acknowledgement obligations and agree to adhere to safe diving practices and dive within the limits of my personal certification level. I further state that I am of lawful age and legally competent to sign this liability release, or that I have obtained the written consent of my parent of guardian.

I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING PARAGRAPHS, FULLY UNDERSTAND THE POTENTIAL DANGERS INCIDENTAL TO THIS TRIP AND ACTIVITY(IES). I AM FULLY AWARE OF THE LEGAL CONSEQUENCES OF SIGNING THIS INSTRUMENT, AND THAT I UNDERSTAND AND AGREE THAT THIS DOCUMENT IS LEGALLY BINDING AND WILL PRECLUDE ME FROM RECOVERING MONETARY DAMAGES TODAY AND ON ALL FUTURE DATES FROM THE ABOVE LISTED ENTITIES AND/OR INDIVIUALS, WHETHER SPECIFICALLY NAMED OR NOT, FOR PERSONAL INJURY, PROPERTY DAMAGE/LOSS OR WRONGFUL DEATH CAUSED BY PRODUCT LIABILITY OR THE NEGLIGENCE OF THE RELEASED PARTIES, WETHER PASSIVE OR ACTIVE.

Type Signature

Draw Signature

Click to Sign

Date: April 27, 2024

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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First Diver's Name

First Name*

Last Name*

Phone*

First Diver's Date of Birth*

First Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

Please check what equipment you will need for your dive trip. Please be advised we are very limited on hire equipment and cannot guarantee we will be able to supply your size. We do provide tanks & weights if needed, please note some trip; the Dive Operator provides these.

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

DISCLAIMER! If you intend on using hire equipment, please remember that they are not equipped with an SMB & whistle. You will need to purchase this to dive unless you already own one. This is a QLD law requirement, if you do not have this you will be unable to dive on your trip. These packs are available in-store for $19.95.

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

Please plan extra time to complete your dive trip in case of delays to our diving schedule. We cannot under any circumstances provide a refund/partial refund due to delays from adverse/unsafe weather conditions or other factors beyond our control. We will ONLY fully refund your dive trip if you cancel within 48 hours of departure.

SEA SICKNESS

It can happen to anyone on any trip. Please make sure you are prepared before your dive-it is too late once you are on the boat. Anti-motion sickness tablets are a preventative, not a cure; it is crucial and our strong recommendation that you take them 30 minutes prior to boarding the vessel. As we are not a pharmacy, we cannot sell medication to divers. You can purchase anti-motion sickness tablets at any chemist over the counter. Adreno does not supply seasickness tablets and we cannot give refunds for sea sickness. Please ensure you notify the pharmacist/doctor that you require them for boating/scubadiving.

Please note that the following questionnaire is not a preventative for your dive, it is purely a safety precaution that ensures our dive professionals can categorise the divers on board into a certain risk category. We want to do our best to keep you safe in the water and for you to get the most out of your dive. Please answer the following questionnaire honestly & to your best capabilities. Adreno is aware that you are a certified diver & that you have completed a dive medical, this is purely as a safety precaution.

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

First Diver's Signature*

Type Signature

Draw Signature

Click to Sign

Second Diver's Name

First Name*

Last Name*

Second Diver's Date of Birth*

Second Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Third Diver's Name

First Name*

Last Name*

Third Diver's Date of Birth*

Third Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Fourth Diver's Name

First Name*

Last Name*

Fourth Diver's Date of Birth*

Fourth Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Fifth Diver's Name

First Name*

Last Name*

Fifth Diver's Date of Birth*

Fifth Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Sixth Diver's Name

First Name*

Last Name*

Sixth Diver's Date of Birth*

Sixth Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Seventh Diver's Name

First Name*

Last Name*

Seventh Diver's Date of Birth*

Seventh Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Eighth Diver's Name

First Name*

Last Name*

Eighth Diver's Date of Birth*

Eighth Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Ninth Diver's Name

First Name*

Last Name*

Ninth Diver's Date of Birth*

Ninth Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Tenth Diver's Name

First Name*

Last Name*

Tenth Diver's Date of Birth*

Tenth Diver's Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

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*

Confirm Email*

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

PLEASE NOTE

Your booking has only been confirmed once a payment has been made for your dive, a booking form does not hold you spot on the Dive Trip.

Email either trips@adreno.com.au to organise a method of payment or call Paul Leslie on 0477 000 987 and pay over the phone. Please let the staff member aware if you require hire equipment OR tank/weight hire so that they can add this onto your total cost.

Please note if you cancel within 48 hours prior to your dive trip we are unable to provide a refund. No shows will be charged the complete price with no refund available.

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 Information

Date of Dive Trip *

Name of Dive Trip*

Do you take regular medication?*

Do you suffer from motion sickness?*

Are you a confident swimmer?*

What training agency (ie SSI) are you certified with?

When was your last dive?

How many dives have you logged in total?

What is your highest level of certification?

Do you have any allergies?*

Do you have any medical conditions that staff/crew need to be notified of?*

If YES, please explain:

Have you already paid for your dive trip?*

HIRE EQUIPMENT

Do you require any hire equipment for your Dive Trip?*

BCD

REGS

1 Tank OR

2 Tanks

Wetsuit

BCD size:

Wetsuit Size:

TANK&WEIGHT HIRE $25
BCD HIRE $30.00
REG HIRE $30.00
WETSUIT HIRE $30.00
SCUBA KIT (Tank, Weights, BC & Reg) $70.00

SPECIAL CONSIDERATIONS FOR ALL DIVING

SEA SICKNESS

Medical Questionnaire:

Have you obtained a previous dive medical?*

Do you need vision aid? (glasses, contacts etc)*

Do you suffer from sinus problems?*

Deafness or ringing tones in your ears?*

Severe motion sickness?*

Do you take anti-motion sickness tablets?*

Migraines*

Prone to fainting/black outs?*

Claustrophobic*

Mental illness that could be triggered while/during diving; anxiety etc*

Previous pneumothorax? (collapsed lung)*

Asthma*

Recent sickness; cold or flu*

Are you pregnant?*

Diabetic; if yes, please specify which type*

1. Could you swim 250m if you had to?*

2. Could you run around the block?*

3. On a scale of 1 to 10 how would you rate your overall fitness level? (10 being the highest level of fitness & 1 being the lowest level of fitness)*

Parent or Guardian's Signature*

Type Signature

Draw Signature

Click to Sign

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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