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PADI Discover Scuba® Diving
Participant Statement

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Diver Medical | Participant Questionnaire

PADI Discover Scuba Diving Participant Statement

Read the following paragraphs carefully. Your answers cannot be changed after you sign! 

This statement, which includes a Medical Questionnaire, a Liability Release and Assumption of Risk Agreement (Statement of Risks and Liability), Non-Agency Disclosure and Acknowledgment and the Discover Scuba Diving Knowledge and Safety Review, informs you of some potential risks involved in scuba diving and of the conduct required of you during the PADI Discover Scuba Diving program. If you are a minor, your parent or guardian must read this Guide and sign on the back panel.

You will also need to learn important safety rules regarding breathing and equalization while scuba diving from the PADI Professional. Scuba diving and the use of scuba equipment without proper supervision or instruction can result in serious injury or death. You must be instructed in its use under the direct supervision of a qualified instructor.

Non-Agency Disclosure and Acknowledgment Agreement

I Agree
I understand and agree that PADI Members (“Members”), including Low Key Watersports and/or any individual PADI Instructors and Divemasters associated with the program in which I am participating, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of PADI Americas, Inc, or its parent, subsidiary and affiliated corporations (“PADI”). I further understand that Member business activities are independent, and are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver training programs, it is not responsible for, nor does it have the right to control, the operation of the Members’ business activities and the day-to-day conduct of PADI programs and supervision of divers by the Members or their associated staff. I further understand and agree on behalf of myself, my heirs and my estate that in the event of an injury or death during this activity, neither I nor my estate shall seek to hold PADI liable for the actions, inactions or negligence of Low Key Watersports and/or the instructors and divemasters associated with the activity.

Liability Release and Assumption of Risk Agreement

I Agree
I hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. 

I Agree
I understand that diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injuries can occur that require treatment in a recompression chamber. I further understand that this program may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with this program in spite of the absence of a recompression chamber or medical facility in proximity to the dive site.  

I Agree
The information I have provided about my medical history on the Medical Questionnaire is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions. 

I Agree
I understand and agree that neither the dive professionals conducting this program, nor the facility through which this program is offered, Low Key Watersports, Ringo Leasing, vehicles and vessels, Savannah’s Boutique. Still Waters, volunteers, affiliates, heirs or assigns nor PADI Americas, Inc., nor its affiliate or subsidiary corporations, nor any of their respective employees, officers, agents or assigns (hereinafter referred to as “Released Parties”) may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occur as a result of my participation in this program or as a result of the negligence of the Released Parties, whether passive or active.  

I Agree
In consideration of being allowed to participate in this program, I hereby personally assume all risks for any harm, injury or damage, whether foreseen or unforeseen, that may befall me while participating in this program, including but not limited to the knowledge development, confined water and/or open water activities. 

I Agree
I further release and hold harmless the Discover Scuba Diving program and the Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my participation in this program. 

I Agree
I further understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this program and that if I am injured as a result of heart attack, panic, hyperventilation, etc., that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same. 

I Agree
I further state that I am of lawful age and legally competent to sign this Liability Release and Assumption of Risk Agreement, or that I have acquired the written consent of my parent or guardian. 

I Agree
I understand that the terms herein are contractual and not a mere recital and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid, that provision shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable provision had never been contained herein. 

I Agree
I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns or beneficiaries may have to sue the Released Parties resulting from my death. I further represent that I have the authority to do so and that my heirs, assigns and beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties. 

I Agree
I understand that I am responsible for my own behavior while on the boat and that it is my responsibility to obey the directives and instructions of the crew for my own safety and that of my fellow passengers.

I Agree
For and in consideration of permitting the undersigned persons to lease the vessel, the undersigned individually, and their individual heirs, executors, administrators, and assigns hereby voluntarily release, discharge, waive and relinquish any and all actions or causes of actions for personal injury, property damage or wrong death occurring to themselves arising at any time against Ocean Runner Power Boat Rental. LLC., or its employees or subcontractors as a result of the lease, use, or operation of the leased vessel. The undersigned, for themselves, their heirs, executors, administrators and assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against Ocean Runner Power Boat Rental, LLC, its employees or subcontractors, arising out of or in any way connected with the lease of the vessel, that they shall hold harmless Ocean Runner Power Boat Rental, LLC, its employees and subcontractors from said claim. It is the intention of the undersigned by this instrument, to exempt and relieve Ocean Runner Power Boat Rental. LLC and its employees and subcontractors from liability for personal injury, property damage, or wrongful death caused by negligence. The undersigned each acknowledge that he/she has completely read this agreement and that they understand the potential dangers incidental to engaging in power boating and that they are fully aware of the legal consequences of signing this document.

I Agree
I give permission to use my photograph publically to promote the Low Key Watersports. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. 

I Agree
The undersigned agrees to refrain from snorkeling or swimming if any alcohol has been consumed.

I, BY THIS INSTRUMENT DO EXEMPT AND RELEASE THE DIVE PROFESSIONALS CONDUCTING THIS PROGRAM, THE FACILITY THROUGH WHICH THE PROGRAM IS CONDUCTED, AND PADI AMERICAS, INC., AND ALL RELATED ENTITIES AND RELEASED PARTIES AS DEFINED ABOVE FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH, HOWEVER CAUSED, INCLUDING BUT NOT LIMITED TO THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT AND NON-AGENCY DISCLOSURE ACKNOWLEDGMENT AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS AND AFFIRM THE MEDICAL QUESTIONNAIRE IS ACCURATE.

 

Medical Questionnaire

Read Carefully! You cannot change your answers later!

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving ftness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

 

Directions

Complete the following questionnaire as a prerequisite to a discover scuba experience, recreational scuba diving or freediving course.

Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

September 18, 2021

First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

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

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information - Read Carefully!
1. I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. (A positive COVID test is considered a diagnosis of COVID-19)*
2. I am over 45 years of age.*
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.*
8. I have had back problems, hernia, ulcers, or diabetes.*
9. I have had stomach or intestine problems, including recent diarrhea.*
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

STOP! Please Read Carefully! 

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

* If you answered YES to questions 3, 5 or 10 above OR to any of the questions on Boxes A,B,C,D,E,F or G , please read and agree to the statement above by signing and dating it 

AND request the physical form from our website, reservations or dive coordinator take all three pages of the form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. 

Participation in a diving course requires your physician's approval.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
A diagnosis of COVID-19.

Box B - I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Box C - I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.
Check your answers carefully!

You cannot change them for ANY REASON after you sign!

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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