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Low Key Student Diver Waiver

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Diver Medical | Participant Questionnaire

Low Key Watersports

Release and Assumption of Risk for Student Diver

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

Release and Assumption of Risk for Snorkelers/Passengers/Student Divers

This is a waiver and release of all your legal rights to sue Low Key Watersports, Inc., Ringo Leasing, vehicles and vessels, Savannah’s Boutique. Still Waters, International PADI Inc., Scuba diving agencies, all officers, shareholders, independent contractors or their employees, officers, agents, instructors, certified assistants, volunteers, affiliates, heirs or assigns (“Released Parties”) for personal injury, property damage, or wrongful death as a result of you participating in snorkeling and/or related activity. Your waiver and release applies even if any injury you sustain is as a result of the negligence of any of the foregoing Released Parties, or as a result of any risk of injury you may have been exposed to whether foreseen or unforeseen, caused by the negligent act or failure to act on the part of any of the Released Parties.

Please place your initials next to each of the following items:

1. I acknowledge that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or legal guardian.

I Agree

2. I am aware of the risks inherent in snorkeling/skin diving and accept these risks.

I Agree

3. I affirm that I am in good mental and physical fitness for snorkeling and that I am not under the influence of any drugs that are contradictory to diving. If I am taking medication, I affirm that I have seen a physician and have approval to snorkel while under the influence of the medication/drugs. 

I Agree

4. I will inspect all of my equipment prior to the activity and will notify the above Released Parties if any of my equipment is not working properly. I will not hold the above listed Released Parties responsible for my failure to safely plan my snorkel. 

I Agree

5. I acknowledge that I am physically fit to skin dive/snorkel, and I will not hold the above Released Parties responsible if I am injured as a result of heart, lung, ear, circulatory problems, or other illnesses that occur while skin diving and/or snorkeling. 

I Agree

6. 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

7. I also understand that skin diving/snorkeling is a physically strenuous activity and that I will be exerting myself during this skin diving/snorkeling excursion, and then if I am injured as a result of a heart attack, panic, hyperventilation, etc., that I expressly assume the risk of said injuries and that I will not hold the above listed Released Parties responsible. 

I Agree

8. The undersigned hereby acknowledges that they were informed that the snorkeling instructor/guide by whom they will be accompanied or instructed is an independent contractor. As an independent contractor the dive instructor is not an employee nor an agent of Low Key Watersports, Inc. Therefore, Low Key Watersports, Inc. does not direct the instructor’s/guide’s activities and is not responsible for the instructor’s/guide’s acts or failure to act. 

I Agree

9. I have agreed by virtue of my signature to this instrument to waive, release, and exempt all Released Parties from any and all liability whatsoever, whether foreseen or unforeseen, for one or more personal injury, property damage or wrongful death caused by the negligent act or failure to act of any of the Released Parties. I further acknowledge that I have agreed to assume all of the risks that I may be exposed to be virtue of my participating in skin diving, snorkeling, and related activities. I further save and hold harmless said course and Released Parties from any claim or lawsuit by me, my family, estate, heirs, or assigns arising out of my enrollment and participation in this course including both claims arising during the course or after I receive my certification.  

I Agree

 

WATERSPORTS AND AQUATIC ACTIVITIES ASSUMPTION OF RISK AND COMPLETE RELEASE OF LIABILITY 



I UNDERSTAND THE PURPOSE OF SIGNING THIS DOCUMENT IS TO EXEMPT AND RELEASE LOW KEY WATERSPORTS, INC. RINGO LEASING, SAVANNAH’S BOUTIQUE &/OR OCEAN RUNNER POWER BOAT RENTAL LLC THEIR OWNERS, EMPLOYEES, AGENTS, AND ASSOCIATED PERSONNEL, AND THEIR BOAT(S) AND/OR EQUIPMENT (WHETHER OWNED, OPERATED, LEASED, OR CHARTERED), HEREINAFTER REFERRED TO AS “RELEASED PARTIES”, AND TO HOLD THESE ENTITIES HARMLESS FROM ANY AND ALL LIABILITIES ARISINGASACONSEQUENCEOF THE FOLLOWING, OR ANY OTHER ACTS OR OMISSIONSON THEIR PART, INCLUDING BUT NOT LIMITED TO NEGLIGENCE OF ANY TYPE. 

1. I UNDERSTAND THERE ARE INHERENT RISKS INVOLVED WITH SWIMMING, SNORKELING, DIVING, BOATING, WATERSPORTS PARASAILING, AND OTHER AQUATIC-BASED ACTIVITIES included but not limited to equipment failure, perils of the sea, action of the sea, wind, waves and boat wake, harm caused by marine creatures (including bites and/or attacks), acts of fellow participants or guests, entering and exiting the water, transferring between boats, aquatic-based activities, the consumption of alcohol, boarding or disembarking boats, and activities on the docks and approaches and I HEREBY ASSUME SUCH RISKS.

2. The inherent risks of the activities include fatigue and/or dizziness caused by or contributed to alcohol consumption, which may diminish my reaction time and increase the risk of accident. I understand and acknowledge the dangers associated with the consumption of alcohol or any mind-altering substance/drugs before and during the activities and I take full responsibility for any injury, loss or damage associated with the consumption of the same. I agree to drink responsibly and to not take drugs prohibited by law before and during the activities.  

3. I UNDERSTAND I HAVE A DUTY TO EXERCISE REASONABLE CARE FOR MY OWN SAFETY AND I AGREE TO DO SO. 4. I assert I am physically fit to swim, snorkel and participate in aquatic-based activities and ride on a boat and/or equipment and I will not hold the RELEASED PARTIES responsible if I am injured as a result of ANY problems (medical, accidental, or otherwise) which occur while swimming, snorkeling, riding on the boat or equipment, or otherwise participating in the trip or activities. 5. If I become distressed during the trip or whilst otherwise participating in activities, I will immediately notify the crew and ask for assistance. 

6. I fully understand the involved boat and/or equipment has limited medical facilities and in the event of illness or injury appropriate medical care must be summoned by radio or telephone and treatment will be delayed until I can be transported to a proper medical facility. I agree in advance to these conditions. 

7. The RELEASED PARTIES have made no representation to me implied or otherwise they or their crew can or will perform safe rescues or render first aid. If I show signs of distress or call for aid, I would like assistance and will not hold the RELEASED PARTIES, their crew, boats, equipment, or passengers responsible for their actions in attempting the performance of rescue or first aid.

8. IT IS MY INTENTION BY THIS INSTRUMENT TO GIVE UP MY RIGHT TO SUE ALL PERSONS OR ENTITIES REFERRED TO HEREIN, WHETHER SPECIFICALLY NAMED OR NOT, AND IT IS ALSO MY INTENTION TO EXEMPT AND RELEASE ALL RELEASED PARTIES AND TO HOLD THESE ENTITIES HARMLESS FROM ANY AND ALL LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE AND I ASSUME ALL RISK IN CONNECTION WITH SWIMMING, SNORKELING, BOATING, AND AQUATIC ACTIVITIES, INCLUDING BUT NOT LIMITED TO THE MAINTENANCE OF THE EQUIPMENT OR ORGANIZATION OF THIS ACTIVITY.

9. I have carefully read this contract in its entirety, fully understand its contents, and agree to the terms and conditions of this contract on behalf of myself, my heirs, and my personal representatives. This document constitutes the final and entire agreement between RELEASED PARTIES and the undersigned. There are NO WARRANTIES expressed or implied, which extend beyond the description of the activity listed on this form. THIS IS A COMPLETE RELEASE OF LIABILITY AND A LEGALLY BINDING CONTRACT.

10. I speak and read and understand the English language and understand the content of this document. The captain and/or crew have explained this document to me.  


I have read this agreement and I am aware it is a release of liability and a contract between me and the RELEASED PARTIES.I sign it of my own free will and agree to be bound by it, from the date of my signature, forever into the future.

Today's Date: June 26, 2022

 


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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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*
Photo Waiver
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.*
Yes
No
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 and/or blood affecting my normal physical or mental performance*
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, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
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.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance

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!

Photo Release

I give permission to use my photograph publicly to promote 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.*
Yes
No
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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