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Travel Waiver & Medical Form

516-997-4864

www.scubadiversusa.com


Today's Date: December 26, 2024

I am aware that Scuba Diving instruction and Diving are hazardous activities, and I am voluntarily participating in these activities with knowledge of the danger involved and hereby agree to accept any and all risks of injury or death. I further understand that by signing this document, I am releasing any claims which I may have against my Scuba Instructor/Tour leader, his/her assistants or against Scuba divers Inc. dba Scuba Network any of it’s employees, franchisees or affiliates as the Sponsor/Promoter of this trip from any liability for personal injury, property damage and/or wrongful death arising from my participating in the Scuba activities that I wish to engage in. I understand that diving with compressed air involves certain risks, and injury can occur which may require treatment in a recompression chamber. I further understand that the open water diving trips which are necessary for training and certification or pleasure may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber, and nonetheless agree to proceed with such dives. I hereby personally assume all risks in connection with said diving for any harm, injury, damage which may befall me as a result of my participating in diving, whether foreseen or unforeseen, and I still wish to proceed with diving in spite of the possible absence of recompression chamber in proximity to the dive site. I have read this form and fully understand that scuba is a dangerous sport and that signing this form, I am giving up any legal rights that I have.

 

 -A valid passport is required for most travel. Responsibility for travel documents is accepted by traveler.

General Liability Release and Express Assumption of Risk

For ALL courses/specialty training programs under sanction through PADI, SDI/TDI, NAUI, HSA or DAN: 

Please read carefully, fill in all blanks and initial each paragraph before signing at bottom.

I hereby affirm that I have been advised and thoroughly informed of the inherent hazards of Scuba diving activities. 

I Agree

Further, I understand that diving with compressed air or oxygen enriched air (nitrox) involves certain inherent risks including decompression sickness, embolism, oxygen toxicity, inert gas narcosis, marine life injuries or other barotraumas/hyperbaric injuries can occur that require treatment in a recompression chamber. I further understand that the open water diving trips, which are necessary for training and certification, may be conducted at a site that is remote, either by time of distance or both from such a recompression chamber. I still choose to proceed with such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site.


I understand and agree that neither my Instructor(s), whether SCUBA Network, freelance, independent, or any affiliated instructors, the facility through which I received my instruction, SCUBA NETWORK, SCUBA DIVERS, INC; SCUBA Network Stores Inc. D/B/A SCUBA Network, its Franchisees, Employees or agents and/or its affiliated instructors, International Training, SDI, TDI and SCUBA Diving International, NAUI, PADI, nor the officers, directors, shareholders, affiliated companies, employees, agents, or assigns of the above listed entities and/or individuals, nor the authors of any materials including texts and tables expressly used for training and certification (hereinafter referred to as “Released Parties”) may be held liable or responsible in any way for any injury, death, or other damages to me or my family, heirs, or assigns that my occur as a result of my participation in this diving class or as a result of the negligence of any party, including the Released Parties, whether passive or active.


In consideration of being allowed to enroll in this course, I hereby personally assume all risks in connections with said course, for any harm, injury, or damage that may befall me while I am enrolled as a student of this course, including all risks connected therewith, whether foreseen or unforeseen.


I further agree to save, defend, indemnify, and hold harmless said course and Released Parties from any claim or lawsuit by me, anyone purporting to act on my behalf, my family, estate, heirs or assigns, arising directly or indirectly out of my enrollment and participation in this course including both claims arising during the course or after I receive my certification even if such claims may be groundless, false or fraudulent.


I also understand that diving activities are physically strenuous and that I will be exerting myself during this diving course, and that if I am injured as a result of heart attached, panic, hyperventilation, oxygen toxicity, inert gas narcosis, drowning, etc. that I expressly assume the risk of said injuries and that I will not hold the above listed individuals or companies responsible for the same, and I agree to defend, indemnify, and hold harmless said course and Released Parties for any such injuries incurred by me.


I understand that these activities may place me deeper than I am able to safely execute a free (without breathing gas) ascent from.


I understand that I may be required to furnish my own equipment and that I am responsible for its operating condition and maintenance.


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 that the terms herein are contractual and not a mere recital and that I have signed this document of my own free act. Further that I understand and agree that, in the event that one or more of the provisions of this agreement, for any reason, is held by a court of competent jurisdiction to be invalid or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and this agreement shall be construed as if such invalid, illegal or unenforceable provision or provisions had never been contained herein.


Non-Agency Disclosure and Acknowledgment Agreement

I understand and agree that PADI Members (“Members”), including and/or any individual PADI Instructors and Dive masters 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 Scuba Network and/or the instructors and dive masters associated with the activity.


IT IS THE INTENTION OF ALL PEOPLE ON THIS WAIVER BY THIS INSTRUMENT TO EXEMPT AND RELEASE MY INSTRUCTORS, SCUBA NETWORK AND ALL OTHER RELATED ENTITIES AND RELEASED PARTIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, OR ARISING OUT OF, DIRECTLY OR INDIRECTLY, INCLUDING, BUT NOT LIMTED TO, THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF AND MY HEIRES.


This document is required for all courses and specialties. No alteration, changes, omissions or revisions may be made.

Today's Date: December 26, 2024


MEDICAL HISTORY STATEMENT: I understand that skin and SCUBA diving are strenuous activities involving significant pressure changes and that normal, healthy heart, lungs, ear and sinus, are essential prerequisites for my safety and well-being. I hereby confirm that to the best of my knowledge my circulatory and respiratory systems and body air spaces are healthy and normal and that I have no severe emotional or neurological problems or communicable diseases. I understand that I need to seek unconditional approval for diving from a licensed physician if I am uncertain as to my physical fitness for the rigors of diving.

MEDICAL HISTORY STATEMENT:  I understand that skin and SCUBA diving are strenuous activities involving significant pressure changes and that normal, healthy heart, lungs, ear and sinus, are essential prerequisites for my safety and well-being. I hereby confirm that to the best of my knowledge my circulatory and respiratory systems and body air spaces are healthy and normal and that I have no severe emotional or neurological problems or communicable diseases. I understand that I need to seek unconditional approval for diving from a licensed physician if I am uncertain as to my physical fitness for the rigors of diving.

Please check the box for applicable medical conditions:
Behavioral health problems
Claustrophobia
Agoraphobia
Epilepsy
Ear or hearing problem
Sinus trouble
Severe hay fever
Heart trouble
High blood pressure
Angina
COVID
Heart surgery
Asthma
Bronchitis
Tuberculosis
Respiratory problems
Back problems
Back/spinal surgery
Diabetes
Hernia
Dizziness or fainting
Recent surgery
Hospitalized
Pregnant
Motion sickness
Physical disability
Serious Injury
Hepatitis
HIV positive
Regular medication
Drug allergies
Alcohol or drug abuse
Rejected from any activity for medical reasons
Any medical condition not listed: Please specify below

Please explain any box you checked:

If you are over 40 of age and can answer yes to any of following:  

Current Smoke:*
No
Yes
High blood pressure:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

List all Medications you are presently taking:

I certify that the above information is correct to the best of my knowledge.

If at any time during your dive training your medical condition changes, notify your NAUI Instructor immediately and complete a new NAUI medical history form for inclusion in your student file.

FOR TRIPS ...you need a medical note clearing you for diving


TRIP INSURANCE NAME AND NUMBER: *

DAN MEMBERSHIP TYPE AND NUMBER: *
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

First Participant's Signature*
Second Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Third Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Fourth Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Fifth Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Sixth Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Seventh Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Eighth Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Ninth Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Tenth Participant's Name

First Name*

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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
TRAVEL RECEIPT

PKG. PRICE: *

EXTRAS: *

TOTAL: *

# NIGHTS: *

HOTEL: *

DESTINATION: *

Arrival Date: *

Departure Date: *

PASSPORT NUMBER: *

EXPIRATION DATE: *

Date of Birth: *

HOME #:

CELL #: *
Insurance

Insurance Carrier*

Insurance Policy Number*
Emergency Contact

First Name*

Last Name*

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


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

Trip Cancellation/Interruption Insurance is highly recommended. The main feature of this insurance provides coverage of the insured is prevented from taking his/her prearranged tour due to either injury, sickness or airline default.


NO, I decline trip Interruption Insurance. AND ASSUME ALL FINANCIAL RESPONSIBILITY.
YES, I'd like to purchase insurance, and I will notify scuba network of the insurance information.

I authorize Scuba Network to bill the charge(s) to my credit card(s) for the services and amounts outlined above and I hereby agree to the cancellation policy and accept the diving waiver described above.



Name as it appears on CC:

Click to customize date box label

TERMS OF CANCELLATION:

Scuba excursions are highly specialized trips that must be planned and prepared well in advance. As a result, penalties for cancellation are severe regardless of reason.

  -ALL PAYMENTS RECEIVED ARE NOT REFUNDABLE

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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