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Bubblemaker Statement
Participant Record
(confidential information)

BUBBLEMAKER ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT

Please read carefully and fill in all blanks before signing.

I the parent/guardian as well as the participant, hereby affirm that we are aware of and understand there are inherent hazards associated with scuba diving which may result in serious injury or death.

We understand there are certain risks associated with aquatic activities conducted in and around a swimming pool or confined water dive site, and we expressly assume the risk of said injuries.

We understand that diving with compressed air involves certain inherent risks and my child will be exposed to these risks. Decompression sickness, embolism or other hyperbaric injuries can occur which require treatment in a recompression chamber. We further understand that this activity may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. We still choose to proceed with this activity in spite of the absence of a recompression chamber in proximity to the activity site.

We understand and agree that neither the dive professionals conducting this activity, nor the facility through which this activity is conducted nor International PADI, Inc., 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 my child, me, my family, our heirs or assigns that may occur as a result of my child’s participation in this activity or as a result of the negligence of any party, including the Released Parties, whether passive or active.

We further understand that scuba diving is a physically strenuous activity and that my child will be exerting him/herself during this activity and that if my child is injured as a result of heart attack, panic, hyperventilation, etc., that we expressly assume the risk of said injuries to my child. We affirm that we will not hold the above listed individuals or companies responsible for the same.

In consideration of my child being allowed to participate in this activity we hereby personally assume all risks in connection with the activity for any harm, injury or damage that may befall my child while participating in the activity, including all risks connected therewith, whether foreseen or unforeseen.

We further release and hold harmless said activity and the Released Parties from any claim or lawsuit by my child, me, or my family, or our estate, heirs or assigns, arising out of my child’s participation in this activity.

We understand and agree this Release is divisible, and any portion herein held to be in violation of any applicable statutes or regulations or any governmental agency having jurisdiction shall affect only that portion held to be invalid or inoperative, and the remaining portions of this Release shall remain in full force and effect.

I further state that I am of lawful age and legally competent to sign this Assumption of Risk and Liability Release Agreement, and as the parent am providing written consent for the participation of my child.

We understand that the terms herein are contractual and not a mere recital and that we have signed this Release of our own free act.

I, THE PARENT/GUARDIAN AND THE PARTICIPANT,

PARTICIPANT, BY THIS INSTRUMENT DO EXEMPT AND RELEASE THE DIVE PROFESSIONALS CONDUCTING THIS ACTIVITY, THE FACILITY THROUGH WHICH THIS ACTIVITY IS CONDUCTED, AND INTERNATIONAL PADI, INC., AND ALL RELATED ENTITIES 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.

WE HAVE FULLY INFORMED OURSELVES OF THE CONTENTS OF THIS ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF, MY CHILD, AND OUR HEIRS.

Date: October 27, 2021

First Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Third Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Fourth Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Fifth Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Sixth Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Seventh Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Eighth Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Ninth Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Tenth Participant's Name

First Name*

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

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

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

Emergency Contact's Name*

Emergency Contact's Phone Number*

Primary Phone *
Click to customize checkboxes *
Home
Work
Cell

Secondary Phone
Click to customize checkboxes
Home
Work
Cell

How did you hear about us? *
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*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

MEDICAL QUESTIONNAIRE

To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant's past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. 

I am currently suffering from a cold or congestion.*
No
Yes
I have a history of respiratory problems or disease.*
No
Yes
I have had asthma, emphysema or tuberculosis.*
No
Yes
I currently have an ear infection.*
No
Yes
I have recurrent ear problems, ear disease or surgery.*
No
Yes
I have a history of sinus problems.*
No
Yes
I have had problems equalizing (popping) my ears with airplane or mountain travel.*
No
Yes
I am diabetic.*
No
Yes
I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).*
No
Yes
I have a history of seizures, dizziness or fainting.*
No
Yes
I have a nervous system disorder.*
No
Yes
I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).*
No
Yes
I have recurrent back problems, history of back or spinal surgery.*
No
Yes
I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).*
No
Yes
I have recently had an operation or illness.*
No
Yes
I am under the care of a physician or have a chronic illness.*
No
Yes
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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