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STUDENT PARTICIPATION FORM

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 equipment of the below-listed persons or entities, 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); Dive And Glide, Inc. (Affiliations: NAUI #F0001239, PADI #25789, SSI #809906, SDI/TDI #1004077, SEI# 306489, DAN #2612833;  National Association of Underwater Instructors, Inc. (NAUI) and subsidiary companies;  Professional Association of Diving Instructors (PADI);  Scuba Schools International (SSI);  Scuba Divers International / Technical Divers International (SDI/TDI);  Scuba Educators International (SEI);  Divers Alert Network (DAN);  Instructor Keith Hintz, NAUI #19722, SSI #4676, SEI #306489;  Instructor Marc Ellis, PADI #82644, SSI #75161;  Instructor Jacob Nelson, PADI #432786, SSI #97135;  Instructor Timothy Burch, SSI #11487, SDI/TDI #18486;  Divemaster Kristine Spence, NAUI #62101;  Divemaster Matthew Spence, NAUI #62102;  Divemaster Chris Schelb, PADI #192048;  Divemaster David Barlow, SDI #21922, and, all pool facilities used for training.

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, hyperventilation, oxygen toxicity, hypoxia, narcosis, aquatic life encounters, drowning, or any other cause, that I expressly assume the risk of these injuries and/or attended 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 representations 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 Michigan, 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.

  April 30, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Third Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Fourth Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Fifth Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Sixth Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Seventh Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Eighth Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Ninth Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Tenth Participant's Name

First Name*

Middle Name

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

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
No
Yes
Parent or Guardian's Email Address

Email*

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Check to receive information, news, and discounts by e-mail.
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What type of information are you interested in receiving from Dive & Glide Scuba via email?
Advanced Diving Classes
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Group Dive Travel - Warm Water
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Which diving organization do you prefer?
NAUI - National Association of Underwater Instructors
PADI - Professional Association of Diving Instructors
SSI- Scuba Schools International
SDI/TDI - Scuba Diving International / Technical Diving International
No Preference

Were you referred to us by a friend or family member? If so, please let us know so we can thank them with a $10 referral credit on their account.
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
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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*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Height *

Weight *
Shirt Size*
Shoe Size*

Emergency Contact *

Emergency Contact's Relationship to Participant *

Emergency Contact's Phone Number *

MEDICAL STATEMENT ~ Participant Record (Confidential Information)

PLEASE READ CAREFULLY BEFORE SIGNING.  

Recreational scuba diving and freediving require good physical and mental health. There are a few medical conditions that 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” in 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: Answer all 10 questions of this preliminary medical information inquiry.  Depending on your answers to these questions, you may be required to obtain your physician's approval to dive.

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 physical or mental performance. *
No
Yes
2. I am over 45 years of age.*
No
Yes
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometers/​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
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
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 disability.*
No
Yes
8. I have had back problems, hernia, ulcers, or diabetes.*
No
Yes
9. I have had stomach or intestine problems, including recent diarrhea.*
No
Yes
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). ***
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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