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Certified Diver Liability Release And Diver Medical Questionnaire


Please read carefully and fill in all blanks before signing.

NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT

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


LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT

I hereby affirm that I am a certified scuba diver trained in safe dive practices, or a student diver under the control and supervision of a certified scuba instructor. I know that skin diving, freediving and scuba diving have inherent risks including those risks associated with boat travel to and from the dive site (hereinafter “Excursion”), which may result in serious injury or death. I understand that scuba diving with compressed air involves certain inherent risks; including but not limited to decompression sickness, embolism or other hyperbaric/air expansion injury that require treatment in a recompression chamber. If I am scuba diving with oxygen enriched air (“Enriched Air”) or other gas blends including oxygen, I also understand that it involves inherent risks of oxygen toxicity and/or improper mixtures of breathing gas. I acknowledge this Excursion includes risks of slipping or falling while on board the boat, being cut or struck by a boat while in the water, injuries occurring while getting on or off a boat, and other perils of the sea. I further understand that the Excursion will be conducted at a site that is remote, either by time or distance or both, from a recompression chamber. I still choose to proceed with the Excursion in spite of the absence of a recompression chamber in proximity to the dive site(s).

I understand and agree that neither Diving Locker ; nor the dive professional(s) who may be present at the dive site, nor PADI Americas, Inc., nor any of their affiliate and subsidiary corporations, nor any of their respective employees, officers, agents, contractors and assigns (hereinafter “Released Parties”) may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occur during the Excursion as a result of my participation in the Excursion or as a result of the negligence of any party, including the Released Parties, whether passive or active.

I affirm I am in good mental and physical fitness for the Excursion. I further state that I will not participate in the Excursion if I am under the influence of alcohol or any drugs that are contraindicated to diving. If I am taking medication, I affirm that I have seen a physician and have approval to dive while under the influence of the medication/drugs. I understand that diving is a physically strenuous activity and that I will be exerting myself during the Excursion and that if I am injured as a result of heart attack, panic, hyperventilation, drowning or any other cause, that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same.

I am aware that safe dive practices suggest diving with a buddy unless trained as a self-reliant diver. I am aware it is my responsibility to plan my dive allowing for my diving experience and limitations, and the prevailing water conditions and environment. I will not hold the Released Parties responsible for my failure to safely plan my dive, dive my plan, and follow the instructions and dive briefing of the dive professional(s).

If diving from a boat, I will be present at and attentive to the briefing given by the boat crew. If there is anything I do not understand I will notify the boat crew or captain immediately. I acknowledge it is my responsibility to plan my dives as no-decompression dives, and within parameters that allow me to make a safety stop before ascending to the surface, arriving on board the vessel with gas remaining in my cylinder as a measure of safety. If I become distressed on the surface I will immediately drop my weights and inflate my BCD (orally or with low pressure inflator) to establish buoyancy on the surface.

I am aware safe dive practices recommend a refresher or guided orientation dive following a period of diving inactivity. I understand such refresher/guided dive is available for an additional fee. If I choose not to follow this recommendation I will not hold the Released Parties responsible for my decision.

I acknowledge Released Parties may provide an in-water guide (hereinafter “Guide”) during the Excursion. The Guide is present to assist in navigation during the dive and identifying local flora and fauna. If I choose to dive with the Guide I acknowledge it is my responsibility to stay in proximity to the Guide during the dive. I assume all risks associated with my choice whether to dive in proximity to the Guide or to dive independent of the Guide. I acknowledge my participation in diving is at my own risk and peril.

I affirm it is my responsibility to inspect all of the equipment I will be using prior to the leaving the dock for the Excursion and that I should not dive if the equipment is not functioning properly. I will not hold the Released Parties responsible for my failure to inspect the equipment prior to diving or if I choose to dive with equipment that may not be functioning properly.

I acknowledge Released Parties have made no representation to me, implied or otherwise, that they or their crew can or will perform affective rescues or render first aid. In the event I show signs of distress or call for aid I would like assistance and will not hold the Released Parties, their crew, dive boats or passengers responsible for their actions in attempting the performance of rescue or first aid.

I hereby state and agree that this Agreement will be effective for all Excursions in which I participate for one (1) year from the date on which I sign this Agreement.

I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. I understand the terms herein are contractual and not a mere recital, and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid, that provision shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable provision had never been contained herein. I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns, or beneficiaries may have to sue the Released Parties resulting from my death. I further represent that I have the authority to do so and that my heirs, assigns, and beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties.

I BY THIS INSTRUMENT, AGREE TO EXEMPT AND RELEASE THE RELEASED PARTIES DEFINED ABOVE FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, INCLUDING BUT NOT LIMITED TO THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE.

I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT, AND LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS.

Participant Signature or Signature of Parent of Guardian (where applicable)


Date: May 9, 2024

 

Diver Medical and Participant Questionnaire

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

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.

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


Date signed: May 9, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
Parent or Guardian's Email Address

Email*

Confirm Email*
Diver Certification Details

Certification Number:

Certification level *

Certification Agency (PADI,SSI, TDI etc.)
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*
Yes -Complete Box A Below
No
2. I am over 45 years of age.*
Yes - Complete Box B Below
No
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.*
Yes
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses.*
Yes - Complete Box C Below
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
Yes
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
Yes - Complete Box D Below
No
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.*
Yes - Complete Box E Below
No
8. I have had back problems, hernia, ulcers, or diabetes.*
Yes - Complete Box F Below
No
9. I have had stomach or intestine problems, including recent diarrhea.*
Yes - Complete Box G Below
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
Yes
No
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement at the bottom of the page by signing and dating it.

Box A - I have/have had:

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).*
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
Yes
No
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.*
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance*
Yes
No

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

I currently smoke or inhale nicotine by other means.*
Yes
No
I have a high cholesterol level.*
Yes
No
I have high blood pressure.*
Yes
No
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).*
Yes
No

Box C - I have/have had:

Sinus surgery within the last 6 months.*
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.*
Yes
No
Recurrent sinusitis within the past 12 months.*
Yes
No
Eye surgery within the past 3 months.*
Yes
No

Box D - I have/have had:

Head injury with loss of consciousness within the past 5 years.*
Yes
No
Persistent neurologic injury or disease.*
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
Yes
No

Box E - I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.*
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.*
Yes
No

Box F - I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.*
Yes
No
Back or spinal surgery within the last 12 months.*
Yes
No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
Yes
No
An uncorrected hernia that limits my physical abilities.*
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
Yes
No

Box G - I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
Yes
No
Dehydration requiring medical intervention within the last 7 days.*
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).*
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
Yes
No
Bariatric surgery within the last 12 months.*
Yes
No

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

* If you answered YES to questions 3, 5 or 10  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 or dive base 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.


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.

Diver Accident Insurance?*
No
Yes

Policy Number
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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