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TRY SCUBA WAIVER

Hello Camp Barney Parent/Guardian,

Try Scuba at Camp Barney is a 1 hour activity pool session for 1 cabin at a time. Each session is conducted and supervised by 3 Dive Georgia certified scuba professionals, in shallow water.

Questions? Emily@divegeorgia.com

Non-Agency Disclosure and Acknowledgment Agreement 

EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH SNORKELING, APNEA DIVING, SCUBA DIVING, FIRST AID, AND RELATED ACTIVITIES

I,   camper name

hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with Snorkeling, Apnea Diving, SCUBA Diving, First Aid, and instruction related thereto (“Diving Activites”). I fully understand that these hazards and risks can lead to severe injury and even loss of life. I understand that Snorkeling, Apnea Diving, SCUBA Diving, and First Aid activities may be conducted at a site that is remote from a recompression chamber and competent medical assistance. Nevertheless, I choose to proceed even in the absence of a recompression chamber and competent medical assistance. Additionally, I understand that there are also hazards and risks associated with Snorkeling, Apnea Diving, SCUBA Diving, First Aid, and related travel, including, but not limited to the possible injury or loss of life as a result of a vessel accident, being hit by a vessel while in or under the water, while boarding, disembarking, existing and/or reboarding the vessel to begin or end diving activites, equipment failure, user error, as well as during travel to and from dive sites. Despite the potential hazards and risks associated with Snorkeling, Apnea Diving SCUBA Diving, First Aid activities, and related actvites which can include but are not limited to, aquatic life encounters, currents, waves, barotraumas (pressure change related injuries), sudden loss of visibility, entrapment underwater in wrecks, caves, vegeta tion, fishing line, fishing nets or debris, I wish to proceed and I freely accept and expressly assume all hazards and risks, that may arise from Snorkeling, Apnea Diving, SCUBA Diving, First Aid activites, and related activities which could result in personal injury, loss of life and property damage to me.

RELEASE OF LIABILITY AND WAIVER OF CLAIMS AGREEMENT:

In consideration of being allowed to participate in Snorkeling, Apnea Diving, SCUBA Diving, and First Aid activities as well as the use of any of the facilities and the use of the equipment of the below listed persons or en es, I hereby agree as follows:

1. TO WAIVE AND RELEASE ANY AND ALL CLAIMS based upon negligence, active or passive with the exception of intentional, wanton or willful misconduct that I may have in the future against any of the following named persons or entities (hereinafter referred to as Releasees); National Association of Underwater Instructors, Inc. (NAUI) and subsidiary companies: Dive Georgia and Dive Georgia Instructors/Staff.

2. To release the Releasees, their officers, directors, employees, representatives, agents and volunteers, from liability and responsibility, whatsoever, for any claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury, property damage or wrongful death arising from Snorkeling, Apnea Diving, SCUBA Diving, First Aid activities, and related activities whether caused by active or passive negligence of the Releasees or otherwise with the exception of gross negligence. By executing this Agreement, I agree to hold the Releasees harmless for any injury or loss of life which may occur to me during Snorkeling, Apnea Diving, SCUBA Diving, and First Aid activities and/or instruction, and any and all future courses of instruction, programs and Snorkeling, Apnea Diving, SCUBA Diving, and First Aid related travel I undertake.

3. I fully understand that Snorkeling, Apnea Diving, SCUBA Diving, and First Aid related activities are physically strenuous and I will be exerting myself during this course of instruction. I understand and agree that if I am injured or killed as a result of heart attack, panic, hyperventillation on, oxygen toxicity, hypoxia, narcosis, aquatic life encounters, drowning or any other cause, that I expressly assume the risk of these injuries and/or a ended death and that I will not hold the Releasees included in this Agreement responsible in any other way.

4. By entering into this Agreement, I am not relying on any oral or written representation or statements made by the Releasees, other than what is set forth in this Agreement. I further agree that this Agreement shall be governed by and interpreted in accordance with the laws of the State of Florida, United States of America.

5. If any provision, section, subsection, clause or phrase of this Agreement is found to be unenforceable or invalid, that portion shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable portion had never been contained in the Agreement. The English language version of this document shall be controlling in all respects and shall prevail in case of any inconsistencies with translated versions.

I fully understand that the terms of this Agreement are contractual in nature and not a mere recital. I further state by way of my signature I have signed this Agreement of my own free act. I hereby declare that I am of legal age and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this Agreement.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT. 

Participant:

_____________________________Date: May 9, 2025_______


Witness Name and Signature:

____________________

Signature of Parent OR Guardian If Participant Is a Minor, and by their signature they, on my behalf release all claims that both they and I have.

Signature of Parent/Guardian 

_____________________________________________ Date: May 9, 2025______

INSTRUCTOR/LEADER CONFIRMATION I HAVE REVIEWED THIS AGREEMENT AND CONFIRM THAT IT HAS BEEN PROPERLY COMPLETED. Signature of Instructor/Leader: Date:  May 9, 2025 Instructor:________________________________________

Please select who will be participating...
AdultMinor
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DIVER MEDICAL - 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.

1. I have/had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
No
Yes - Go to Box A
2. I am over 45 years of age.*
No
Yes - Go to box B
*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. *
No
Yes
4. I have had problems with my eyes, ears, or nasal passages/sinuses. *
No
Yes - Go to Box C
*5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
No
Yes
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
No
Yes - Go to box D
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 or developmental disability. *
No
Yes - Go to box E
8. I have had back problems, hernia, ulcers, or diabetes. *
No
Yes - Go to box F
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes - Go to box G
*10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). *
No
Yes

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

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions. 


I agree*
No
Yes

Type you full name for agreement *

Today’s Date *

OR

*IF YOU ANSWERED YES to questions 3, 5 or 10 above OR to any of the questions on page 2 (Box A - Box G), please read and agree to the statement above by signing and dating it AND take all pages of this form (Participant Questionnaire and the Physician’s Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician’s approval



BOX A - I HAVE/HAVE HAD:

Answer All Questions Below

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

BOX B - I AM OVER 45 YEARS OF AGE AND:

Answer All Questions Below


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

BOX C - I HAVE/HAVE HAD:

Answer All Questions Below



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

BOX D - I HAVE/HAVE HAD:

Answer All Questions Below



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

BOX E - I HAVE/HAVE HAD:

Answer All Questions Below

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

BOX F - I HAVE/HAVE HAD:

Answer All Questions Below

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

BOX G - I HAVE/HAVE HAD:

Answer All Questions Below

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

Diver Medical | Medical Examiner’s Evaluation Form


__________________________________________________

Participant Name


________________________

Birthdate (dd/mm/yyyy)

The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba diving or freediving training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas rele- vant to your patient as part of your evaluation

EVALUATION RESULT

Choose One Below:


Approved – I find no conditions that I consider incompatible with recreational scuba diving or freediving.*
Yes
Not approved – I find conditions that I consider incompatible with recreational scuba diving or freediving.*
Yes

_____________________________________________                                                    

Signature of certified medical doctor or other legally certified medical provider                    


_________________

Date (dd/mm/yyyy)


_____________________________________________

Medical Examiner’s Name


_____________________________________________

Clinical Degrees/Credentials


_____________________________________________

Clinic/Hospital Address


____________________________

Phone


_____________________________    

Email



Physician/Clinic Stamp:

First Participant’s Name

First Name*

Last Name*
First Participant’s Date of Birth*
First Participant’s Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Participant's Full Name
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 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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