If there is any YES answers, and after continuing to Box A,B,C,D,E,F or G - You CANNOT dive without Our Doctors Release form. Call 808-264-8198 immediately!
Please read the following paragraphs carefully and check the appropriate box's before signing. This statement, which includes a Medical Questionnaire, Discover Scuba Diving / Introductory Scuba Diving Course & Dive Safe Practices Statement and a Statement of Risks and Liability, informs you of some potential risks involved in scuba diving and of the conduct required of you during the Discover Scuba Diving / Introductory Scuba Diving Course & Dive program. Your signature is required to participate in the program. If You are a minor, you must have the Participant Statement (which includes and acknowledges the Medical Questionnaire, the Discover Scuba Diving / Introductory Scuba Diving Course & Dive Safe Practices and the Statement of Risks and Liability) signed by your parent or guardian. You will also need to learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury or death. You must be thoroughly instructed in its use under the direct supervision of a qualified instructor to use it safely. Medical Questionnaire Scuba diving is an exciting and demanding activity. To scuba dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs, should not dive. If Taking medication, consult your doctor before participating in this program. The purpose of this medical history questionnaire is to find out if you should be examined by a doctor before participating in recreational scuba diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety while diving and you must seek the advice of a physician. Please answer the following questions on your past and present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with a Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to a physician. Discover Scuba Diving / Introductory Scuba Diving Course & Dive Practices Statement These practices have been compiled for your review and acknowledgment and are intended to increase your comfort and safety in diving. I understand that upon completing the Discover Scuba Diving / Introductory Scuba Diving Course & Dive, I will not be qualified to dive independently without a certified professional guiding me.
To equalize my ears and sinus air spaces, I will need to blow gently against pinched nostrils every few feet/one meter while descending.
If I have discomfort in my ears or sinuses during descent, I should stop my descent and alert my instructor.
Underwater, I should breathe slowly, deeply, continuously and never hold my breath.
I should respect underwater life and not touch, tease or harass an underwater organism since it may harm me and/or I may harm it.
I can seek further training from another Dive Center, and Instructor to become certified to dive without a professional guide. Statement of Risks and Liability I hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death.I affirm I have read and understand the Safe Diving Practices and have had any questions answered to my satisfaction. I understand the importance and purposes of these established practices. I recognize they are for my safety and well being, and that failure to adhere to them can place me in jeopardy when diving. I understand that diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. I further understand that this program may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with this program in spite of the absence of a recompression chamber in proximity to the dive site. The information I have provided about my medical history on the Medical Questionnaire is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions. I further understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this program. I further state that I am of lawful age and legally competent to sign this Statement of Risks and Liability, or that I have acquired the written consent of my parent or guardian. I understand and agree that neither the dive professionals conducting this program, Tyrone Burnett, DBA; In2Scuba Diving Maui Dive Company LLC. Nor the facility through which this program is conducted, nor their affiliate or subsidiary corporations, employees, officers, agents or assigns (hereinafter referred to as “Released Parties”) accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any matter or condition under my control that amounts to my own contributory negligence. In the absence of any negligence or other breach of duty by the dive professionals conducting this program, Tyrone Burnett, DBA; In2Scuba Diving Maui Dive Company LLC, nor the facility through which this program is offered and all released defined above, my participation in this diving program is entirely at my own risk. I have fully informed myself of the contents of this Statement of Risks and Liability by reading it before signing it. Today's Date: October 9, 2024 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, You cannot dive.
If there is a YES answer after continuing to Box A,B,C,D,E,F or G - You CANNOT dive without Our Doctors Release form. Call 808-264-8198 immediately!
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