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DISCOVER SCUBA WAIVER

Non-Agency Disclosure and Acknowledgment Agreement 

I Agree
I understand and agree that PADI Members (“Members”), including Dive Georgia, LLC 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 Dive Georgia, LLC and/or the instructors and divemasters associated with the activity.

Liability Release and Assumption of Risk Agreement 

I Agree
I, hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. I understand that 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. I further understand that the open water diving trips which are necessary for training and for certification 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 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), Staff of Dive Georgia, LLC, the facility through which I receive my instruction, Dive Georgia, LLC, nor PADI Americas, Inc., nor its affiliate and subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns (hereinafter referred to as “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 as a result of my participation in this diving program or as a result of the negligence of any party, including the Released Parties, whether passive or active. In consideration of being allowed to participate in this course (and optional Adventure Dive), hereinafter referred to as “program,” I hereby personally assume all risks of this program, whether foreseen or unforeseen, that may befall me while I am a participant in this program including, but not limited to, the academics, confined water and/or open water activities. I further release, exempt and hold harmless said program and Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my enrollment and participation in this program including both claims arising during the program or after I receive my certification. I also understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this program, 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 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 I have the authority to do so and that my heirs, assigns, or beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties.

I hereby grant Dive Georgia, affiliated companies of Dive Georgia, companies, staff, and instructors permission to solicit and market to me directly via fax, email, text, SMS, mail and phone. If I wish to change this permission, I agree to use the “OPT OUT” option provided in each marketing media, whether via link, page, call, or reply text/SMS.

I Agree
BY THIS INSTRUMENT AGREE TO EXEMPT AND RELEASE MY INSTRUCTORS, Staff of Dive Georgia, LLC, THE FACILITY THROUGH WHICH I RECEIVE MY INSTRUCTION, Dive Georgia, LLC, AND PADI AMERICAS, INC., AND ALL RELATED ENTITIES AS 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 Agree
I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLDGEMENT AGREEMENT AND LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS.

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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*
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 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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