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    Participant Record

    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

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    Participant Signature

    If you answered NO to all 10 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.

    ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT

    Please read carefully and fill in all blanks before signing

    participant, hereby affirm that we are aware of and understand there are inherent hazards associated with scuba diving which may result in serious injury or death.

    We understand there are certain risks associated with aquatic activities conducted in and around a swimming pool or confined water dive site, and we expressly assume the risk of said injuries.
    We understand that diving with compressed air involves certain inherent risks and my child will be exposed to these risks. Decompression sickness, embolism or other hyperbaric injuries can occur which require treatment in a recompression chamber. We further understand that this activity may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. We still choose to proceed with this activity in spite of the absence of a recompression chamber in proximity to the activity site.

    We understand and agree that neither the dive professionals conducting this activity, nor the facility through which this activity is conducted,

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    nor International PADI, Inc., nor any of their respective employees, officers, agents 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 my child, me, my family, our heirs or assigns that may occur as a result of my child’s participation in this activity or as a result of the negligence of any party, including the Released Parties, whether passive or active.

    We further understand that scuba diving is a physically strenuous activity and that my child will be exerting him/herself during this activity and that if my child is injured as a result of heart attack, panic, hyperventilation, etc., that we expressly assume the risk of said injuries to my child. We affirm that we will not hold the above listed individuals or companies responsible for the same
    In consideration of my child being allowed to participate in this activity we hereby personally assume all risks in connection with the activity for any harm, injury or damage that may befall my child while participating in the activity, including all risks connected therewith, whether foreseen or unforeseen.
    We further release and hold harmless said activity and the Released Parties from any claim or lawsuit by my child, me, or my family, or our estate, heirs or assigns, arising out of my child’s participation in this activity.
    We understand and agree this Release is divisible, and any portion herein held to be in violation of any applicable statutes or regulations or any governmental agency having jurisdiction shall affect only that portion held to be invalid or inoperative, and the remaining portions of this Release shall remain in full force and effect.
    I further state that I am of lawful age and legally competent to sign this Assumption of Risk and Liability Release Agreement, and as the parent am providing written consent for the participation of my child.

    We understand that the terms herein are contractual and not a mere recital and that we have signed this Release of our own free act.

    PARTICIPANT, BY THIS INSTRUMENT DO EXEMPT AND RELEASE THE DIVE PROFESSIONALS CONDUCTING THIS ACTIVITY, THE FACILITY THROUGH WHICH THIS ACTIVITY IS CONDUCTED, AND INTERNATIONAL PADI, 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.
    WE HAVE FULLY INFORMED OURSELVES OF THE CONTENTS OF THIS ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF, MY CHILD, AND OUR HEIRS

    Youth Diving: Responsibility and Risks Acknowledgment

    (Please read carefully, fill in all blanks, and sign and date below.)

    have viewed and understand the Youth Diving: Responsibility and Risks video or flip chart. We affirm we have been advised and thoroughly informed that diving is an adventure sport with inherent risks to the participant. These risks may include, but are not limited to, pressure related injuries affecting the lungs, sinuses & ears, drowning, panic & other serious injury or death. We also understand our responsibilities, as parent and participant (child), in participating in scuba activities and agree to accept those responsibilities.

    As the parent/guardian of the minor child, I/we understand and agree it is solely my/our responsibility to evaluate whether my/our child should participate in scuba activities. Our decision is based upon our knowledge of the mental, physical and emotional abilities of our child, as well as his/her medical history. I/we understand and agree it is my/our responsibility to discuss with a physician any questions I/we have regarding my/our child’s medical history and participation in this activity.

    I/we understand and agree that it is my/our responsibility to continue to monitor the abilities and health of my/our child to determine whether he/she should continue in this program and continue to dive after the program.
    I/we agree to abide by all supervisory and depth limitations that may accompany my/our child’s PADI certification.
    I/we understand that PADI certifies instructors/dive centres and provides materials for programs developed by PADI.
    I/we understand that the dive centre/resort and the instructor are responsible for the conduct and supervision of this activity
    I/we understand my responsibilities and those of my child as set forth in the Youth Diving Responsibilities and Risk video or flip chart.
    I/we have read this Acknowledgment, understand and agree to the terms and conditions, and understand and agree that this Acknowledgment is a binding contract between us, the dive professional, the dive facility and PADI.

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