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HEALTH DECLARATION FORM / COVID-19 

Read this statement prior to signing it. You must complete this additional medical questionnaire to enroll in a diver training program or to participate in any diving activity. If you are a minor, you must have this statement signed by your parent or guardian.

DIVER MEDICAL QUESTIONNAIRE

The purpose of this medical questionnaire is to ensure that you are medically fit to dive. Please answer the following questions with a YES or NO. If you are not sure, answer YES. A positive response means that there may be a preexisting condition that could affect your safety while diving. If any of these items apply to you, we must request that you consult with a physician, preferably a specialist in diving medicine, prior to participating in diving activities. 

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for any omissions in disclosing my existing or past health conditions.

I also commit to inform about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration. 

ADDITIONAL DECLARATIONS / COVID-19

I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by Flamingo DOS N.V. d/b/a Divi Dive Bonaire, and will take all reasonable preventive steps that may be recommended by Flamingo DOS N.V. d/b/a Divi Dive Bonaire, or any relevant public authority. 

I Agree

I WILL accept and observe all instructions by Flamingo DOS N.V. d/b/a Divi Dive Bonaire intended to abide by all existing regulations, required to help prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities. 

I Agree

I ACKNOWLEDGE and ACCEPT that this declaration will be considered as my consent to Flamingo DOS N.V. d/b/a Divi Dive Bonaire to retain this declaration and disclose it to any relevant authority or service provider for the purposes of ensuring the safety of any third parties that may come in contact with me prior to, during, and after any diving activity. 

I Agree

Please note

COVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalesce before returning to full activities – a process that can take weeks or months depending on symptom severity (1).

MEDICAL RECOMMENDATIONS (2):

  • Divers who have had symptomatic COVID-19, should wait a minimum of TWO months, preferable THREE, before resuming their diving activities.
  • Divers who have tested positive with COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.
  • Divers who have been hospitalised with pulmonary symptoms related to COVID-19, should, after a three-month waiting period, undergo complete
  • pulmonary function testing as well as a cardiac evaluation with echocardiography and exercise test (exercise electrocardiography) to ascertain normal cardiac function prior to their return to diving.
  • GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe / Divers Alert Network).

REFERENCES

  1. (1) Return to Diving Post COVID-19 - issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA.
  2. (2) Diving after COVID-19 pulmonary infection. A position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG). 

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

The Form has been developed by the DAN Europe Medical Division team, based on information available as of May 2020. The epidemiological situation is constantly evolving.As a result, this document may be subject to changes and updates. 

Today's Date: April 1, 2023

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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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*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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