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PADI Recreational Courses

Use this for all PADI scuba classes (except Enriched Air Nitrox) taken at Nautilus Aquatics 

CONTINUING WAIVER & RELEASE OF LIABILITY, ASSUMPTION OF RISK & INDEMNITY, AND EMERGENCY CARE PERMISSION

PLEASE READ CAREFULLY BEFORE SIGNING BECAUSE THIS IS A CONTINUING RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS. IT ALSO GRANTS CONTINUING PERMISSION FOR EMERGENCY CARE.

In consideration of permitting me, (participant), to enroll in a swim, snorkeling, or scuba diving instructional course and/or participate in Swimming, Snorkeling, Scuba Diving, Swim Parties, Physical Activities, and Related Operations (hereafter known as “Water Activities”) conducted by Diventures Holdings, LLC or any Diventures Subsidiaries (as defined below), beginning on April 24, 2024 I agree for myself, my personal representatives, heirs and next of kin:

I hereby acknowledge that Water Activities are potentially dangerous activities and involve the inherent risk of serious injury (including paralysis), death and/or property damage both in and under the water as well as on the pool deck itself.

I hereby release, waive, discharge and agree not to sue Diventures Holdings, LLC; its subsidiaries Diventures, LLC, Diventures Iowa, LLC, Diventures Springfield, LLC, Diventures Madison, LLC, Diventures Columbia, LLC, Diventures Atlanta, LLC, Diventures Lexington, LLC, Diventures Kansas City, LLC, Diventures Lincoln, LLC, Diventures Battle Creek, LLC, Diventures Arizona, LLC, Diventures Marietta, LLC, Diventures Memphis, LLC, Diventures Little Rock, LLC, and Diventures Virginia, LLC, Diventures Colorado Springs, LLC (collectively, “Diventures Subsidiaries”) and their respective facilities, staff, officers, instructors, agents or employees (collectively, the “Releasees”) from all liability to myself, my minor child(ren), my personal representatives, signs, heirs and next of kin for any and all loss or damage and any claim or demands therefore on account of injury to my person or property or resulting in my death, now and forever, arising out of or related to participation and/or instruction in said course, activities or any other related Water Activities that may occur.

I hereby assume full responsibility for any risk of bodily injury, death or property damage, now and forever, arising out of or related to participation and/or instruction in said course, Water Activities, or any other swimming/snorkeling operations conducted by Diventures Holdings, LLC or any Diventures Subsidiaries.

I hereby acknowledge that this Waiver and Release of Liability is intended to be as broad and inclusive as permitted by the laws of the state in which the activities are conducted, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I hereby assume full responsibility for determining the need for and providing an interpreter for a language other than English within the facility.

I acknowledge that it is my responsibility to provide for my own and/or my child(ren)’s own accident and health coverage while participating in Water Activities.

In the event I cannot be reached and/or am incapacitated or otherwise able to give consent, I give permission for emergency medical, surgical and hospital treatment and procedures to be performed by a licensed physician or hospital, when deemed immediately necessary to safeguard my/my child(ren)’s health. I relieve Releasees of any and all responsibility for action(s) taken by the doctor(s), hospitals, or other medical care providers in the treatment and attendance of me or my child.

I agree that this waiver, release of liability, assumption of the risk, and consent for emergency medical, surgical and hospital treatment shall be continuing and effective for all Water Activities conducted by or on behalf of the above named Releasees for a period of time beginning with the execution of this document and terminating at 11:59 P.M., CST, on the 365th day after the date on which this document was signed.

I Agree

Staff Release

By signing this document, I am in full understanding of what constitutes “Staff of Nautilus Aquatics” or “All Staff of Nautilus Aquatics” as referenced in the liability waivers below. I further understand that this list is subject to change at any time to encompass any and all individuals who may be present during SCUBA training or any associated activity. It is the sole decision of the owners of Diventures Virginia, LLC, dba Nautilus Aquatics, henceforth known as Nautilus Aquatics, to determine what individuals will be considered part of the staff at any time. By signing this document, I acknowledge that I am in full understanding that all liability is being waived for all associates of Nautilus Aquatics, to include any facility or other business or vessel. I further understand that Nautilus Aquatics will not be held responsible for any incident or misadventure that may occur before, during or after any activity. By signing this document, I am agreeing that none of my associates or family members can hold Nautilus Aquatics or any of their associates responsible, or liable, for any incident or misadventure before, during, or after any activity. I understand that all of these conditions apply to any minor (individual under the age of 18 years) that I may be signing for as well, and will accept full responsibility for their actions at all times. 

I Agree

PADI Non-Agency Disclosure and Acknowledgment Agreement

I understand and agree that PADI Members (“Members”), including Nautilus Aquatics 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 Nautilus Aquatics and/or the instructors and divemasters associated with the activity.

I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT BY READING IT BEFORE I SIGNED IT ON BEHALF OF MYSELF AND MY HEIRS.

I Agree

PADI Liability Release and Assumption of Risk Agreement

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), All Staff of Nautilus Aquatics, the facility through which I receive my instruction, Nautilus Aquatics, 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 beneciaries 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 stopped from claiming otherwise because of my representations to the Released Parties.

I BY THIS INSTRUMENT AGREE TO EXEMPT AND RELEASE MY INSTRUCTORS, All Staff of Nautilus Aquatics, THE FACILITY THROUGH WHICH I RECEIVE MY INSTRUCTION, Nautilus Aquatics, 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.

Standard Safe Diving Practices Statement of Understanding

This is a statement in which you are informed of the established safe diving practices for skin and scuba diving. These practices have been compiled for your review and acknowledgement and are intended to increase your comfort and safety in diving. Your signature on this statement is required as proof that you are aware of these safe diving practices. Read and discuss the statement prior to signing it. If you are a minor, this form must also be signed by a parent or guardian.

I understand that as a diver I should:

1. Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and refresh myself on important information.

I Agree

2. Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which I am experienced, postpone diving or select an alternate site with better conditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave or technical diving unless specically trained to do so.

I Agree

3. Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correct fit and function prior to each dive. Have a buoyancy control device, low-pressure buoyancy control inflation system, submersible pressure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—whichever you are trained to use) when scuba diving. Deny use of my equipment to uncertified divers.

I Agree

4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recognize that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed six months.

I Agree

5. Adhere to the buddy system throughout every dive. Plan dives – including communications, procedures for reuniting in case of separation and emergency procedures – with my buddy.

I Agree

6. Be proficient in dive planning (dive computer or dive table use). Make all dives no decompression dives and allow a margin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 meters/60 feet per minute. Be a SAFE diver – Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 meters/15 feet for three minutes or longer.

I Agree

7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving. Carry at least one surface signaling device (such as signal tube, whistle, mirror).

I Agree

8. Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessive hyperventilation when breath-hold diving. Avoid overexertion while in and underwater and dive within my limitations.

I Agree

9. Use a boat, float or other surface support station, whenever feasible.

I Agree

10. Know and obey local dive laws and regulations, including fish and game and dive flag laws.

I Agree

I understand the importance and purposes of these established practices. I recognize they are for my own safety and well-being, and that failure to adhere to them can place me in jeopardy when diving.

Today's date: April 24, 2024



Please select who will be participating...
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical Questionnaire
Please Choose The Course You Are Taking...*

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.**
2. I am over 45 years of age.**
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.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.**
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.**
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.**
8. I have had back problems, hernia, ulcers, or diabetes.**
9. I have had stomach or intestine problems, including recent diarrhea.**
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the PARTICIPANT STATEMENT below.

* If you answered YES to questions 35 or 10 above please read and agree to the Participant Statement below AND request the physical form (Participant Questionnaire and the Physician's Evaluation Form) from your instructor or dive center to take to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.

** If you answered YES to questions 1, 2, 4, 6, 7, 8, or 9 please continue to the appropriate Box(es) below to complete your questionnaire to determine if participation in a diving course requires your physician's approval.


Box A - Complete this section if you answered YES to Question 1 above.


I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
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.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.


Box B - Complete this section if you answered YES to Question 2 above. 


I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
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).


Box C - Complete this section if you answered YES to Question 4 above. 


I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.


Box D - Complete this section if you answered YES to Question 6 above. 


I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.


Box E - Complete this section if you answered YES to Question 7 above. 


I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.


Box F - Complete this section if you answered YES to Question 8 above. 


I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.


Box G - Complete this section if you answered YES to Question 9 above. 


I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.


* If you answered YES to any of the questions in Boxes A, B, C, D, E, F or G, please read the Participant Statement below AND request the physical form (Participant Questionnaire and the Physician's Evaluation Form) from your instructor or dive center to take to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.

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.


Today's Date: *
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Photo/Media Release

I acknowledge that photos or videos taken during my course with Diventures, may include me or the undersigned minor(s).

I hereby authorize Diventures to publish photographs taken of me and/or the undersigned minor children, and/or names, for use in Diventures' marketing material, social media and website. I release Diventures from any expectation of confidentiality for the undersigned minor children and myself. I attest that I am the parent or legal guardian of the children listed below and that I have the authority to authorize Diventures to use their photographs and names.

I acknowledge that this photo participation is voluntary, and neither the minor children nor I will receive financial compensation. I further agree that our participation in any marketing piece produced by Diventures confers no rights of ownership whatsoever. I release Diventures, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.


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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Questionnaire
Please Choose The Course You Are Taking...*

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.**
2. I am over 45 years of age.**
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.*
4. I have had problems with my eyes, ears, or nasal passages/sinuses.**
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.**
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.**
8. I have had back problems, hernia, ulcers, or diabetes.**
9. I have had stomach or intestine problems, including recent diarrhea.**
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the PARTICIPANT STATEMENT below.

* If you answered YES to questions 35 or 10 above please read and agree to the Participant Statement below AND request the physical form (Participant Questionnaire and the Physician's Evaluation Form) from your instructor or dive center to take to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.

** If you answered YES to questions 1, 2, 4, 6, 7, 8, or 9 please continue to the appropriate Box(es) below to complete your questionnaire to determine if participation in a diving course requires your physician's approval.


Box A - Complete this section if you answered YES to Question 1 above.


I have/have had:

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
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.
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.


Box B - Complete this section if you answered YES to Question 2 above. 


I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means.
I have a high cholesterol level.
I have high blood pressure.
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).


Box C - Complete this section if you answered YES to Question 4 above. 


I have/have had:

Sinus surgery within the last 6 months.
Ear disease or ear surgery, hearing loss, or problems with balance.
Recurrent sinusitis within the past 12 months.
Eye surgery within the past 3 months.


Box D - Complete this section if you answered YES to Question 6 above. 


I have/have had:

Head injury with loss of consciousness within the past 5 years.
Persistent neurologic injury or disease.
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Epilepsy, seizures, or convulsions, OR take medications to prevent them.


Box E - Complete this section if you answered YES to Question 7 above. 


I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.
An addiction to drugs or alcohol requiring treatment within the last 5 years.


Box F - Complete this section if you answered YES to Question 8 above. 


I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.
An uncorrected hernia that limits my physical abilities.
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.


Box G - Complete this section if you answered YES to Question 9 above. 


I have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Dehydration requiring medical intervention within the last 7 days.
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Active or uncontrolled ulcerative colitis or Crohn's disease.
Bariatric surgery within the last 12 months.


* If you answered YES to any of the questions in Boxes A, B, C, D, E, F or G, please read the Participant Statement below AND request the physical form (Participant Questionnaire and the Physician's Evaluation Form) from your instructor or dive center to take to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.

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.


Today's Date: *
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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