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Snorkelling Assessment | Medical Declaration

A snorkelling assessment and medical declaration must be completed for all guests wanting to snorkel with Pilgrim Magnetic Island.

I understand that the purpose of signing this document is to exempt and release Pilgrim Sailing Pty owners, employees, agents, and associated personnel, and their boats (whether owned, operated, leased or chartered), hereinafter referred to as “released parties”, and to hold these entities harmless from any and all liabilities arising as a consequence of the following, or any other acts or omissions on their part, including but not limited to negligence of any type. 

I UNDERSTAND THAT THERE ARE INHERENT RISKS INVOLVED WITH SNORKELLING, including but not limited to heart attack, panic, hyperventilation, drowning, air expansion, decompression sickness, equipment failure, perils of the sea, harm caused by marine creatures (including bites), being cut or struck by a boat while in the water, acts of fellow participants, entering and exiting the water, boarding or disembarking boats, and activities on the beach and I hereby assume such risks.

I WILL INSPECT ALL OF MY OWN AND RENTED EQUIPMENT PRIOR TO THE ACTIVITY. I will not hold the Released Parties responsible for my failure to inspect my own and rented equipment or if I choose to snorkel with equipment that may not be functioning properly. 

I fully understand that the involved boat has limited medical facilities and that in the event of illness or injury appropriate medical care must be summoned by radio and treatment will be delayed until I can be transported to a proper medical facility. I agree in advance to these conditions. Pilgrim Sailing Pty Ltd have made no representation to me implied or otherwise that they or their crew can or will perform safe 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, or passengers responsible for their actions in attempting the performance or rescue or first aid. 

It is my intention by this instrument to give up my right to sue all persons or entities referred to herein, whether specifically named or not, and it is also my intention to exempt and release all released parties and to hold these entities harmless from any and all liability for personal injury, property damage or wrongful death or other damage to me or my family, heirs, caused by negligence or gross negligence and I assume all risk in connection with snorkelling, scuba diving and boating activities, including but not limited to the maintenance of the equipment or organisation of this activity. 

I have carefully read this contract in its entirety, and fully understand its contents, my participation in this activity is entirely at my own risk and agree to the terms and conditions of this contract on behalf of myself, my heirs, and my personal representatives. 

I have read and understand the PARTICIPANT OBLIGATIONS and agree to adhere to safe diving practices and snorkel within my capability limits. I further state that I am of lawful age and legally competent to sign this liability release, or that I have obtained the written consent of my parent or guardian. 

I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING PARAGRAPHS, FULLY UNDERSTAND THE POTENTIAL DANGERS INCIDENTAL TO THIS TRIP AND ACTIVITY(IES), AM FULLY AWARE OF THE LEGAL CONSEQUENCES OF SIGNING THIS INSTRUMENT, AND THAT I UNDERSTAND AND AGREE THAT THIS DOCUMENT IS LEGALLY BINDING AND WILL PRECLUDE ME FROM RECOVERING MONETARY DAMAGES FROM THE ABOVE LISTED ENTITIES AND/OR INDIVIDUALS, WHETHER SPECIFICALLY NAMED OR NOT, FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY PRODUCT LIABILITY OR THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE. 

Participant’s Obligations

I declare that I am in good mental and physical fitness for snorkelling and boating and that I am not under the influence of alcohol, nor am I under the influence of any drugs that are contradictory to snorkelling. 

If I am taking medication, I declare that I have seen a physician and have approval to snorkel while under the influence of the medication/drugs. 

I understand that snorkelling is a physically strenuous activity that I will be exerting myself during this activity and that if I am injured as a result of heart attack, panic, hyperventilation, etc., I assume the risk of said injuries I will not hold the Released Parties responsible for the same. 

I understand that concealment of any medical or physical condition might put my life or health or the life or health of others at risk. 

I have been advised that the activities may involve strenuous physical activity even in calm water and that older people are at an increased risk of death and injury due to a higher incidence of medical conditions made worse by physical exertion, such as heart disease and stroke. 

I have been advised to tell the Pilgrim Magnetic Island crew if I have any concerns about medical conditions, fitness levels, and swimming ability. 

Pilgrim Sailing Pty Ltd reserves the right in its absolute unfettered discretion, to refuse to allow me to participate in the activities or to cancel any activities at their discretion, at any time, in the interest of safety or other factors.


First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
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*
Parent or Guardian's Date of Birth*
Parent or Guardian's Fitness & Snorkelling Ability
Please rate your current level of swimming ability*
Poor
Average
Good
Please rate your current level of snorkelling ability*
Poor
Average
Good
Please rate your current level of fitness*
Poor
Average
Good
Are you intending to breathe-hold dive (free dive)?*
No
Yes
Are you suffering from any medical condition which may be made worse by exertion? (e.g. asthma, heart condition, lung disease)*
No
Yes
Are you suffering from any condition which may affect your consciousness? (e.g. epilepsy, diabetes)*
No
Yes
Are you taking any prescribed medication (other than oral contraception)?*
No
Yes

If so, please list medication you are taking.
Do you smoke?*
No
Yes
Are you overweight?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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