San Diego Scuba Guide Release & Medical Form

SanDiegoScubaGuide.com 858-397-8213 davor@sandiegoscubaguide.com
Medical History Information Form
Student / Diver Name: *

First Name Last Name
Medical History Statement: I understand that skin and scuba diving are strenuous activities involving significant pressure changes and that normal, healthy heart, lungs, ear, and sinus, are essential for my safety and well-being. I hereby confirm that to the best of my knowledge my circulatory and respiratory systems and body air spaces are healthy and normal and that I have no severe emotional or neurological problems or communicable diseases. I understand that I need to seek unconditional approval for diving from a licensed physician if I am uncertain as to my physical fitness for the rigors of diving.
Put a check mark next to all the following that applies to you.
Behavioral health problems
Bronchitis
Glasses or contact lenses
Claustrophobia
Tuberculosis
Agoraphobia
Dental plates
Respiratory problems
Physical disability
Migraine Headaches
Back problems
Serious injury
Epilepsy
Back/spinal surgery
Over 40 years old
Ear or hearing problem
Diabetes
Hepatitis
Ulcers
HIV positive
Trouble Equalizing pressure
Sinus trouble
Colostomy
Regular medication
Severe hay fever
Hernia
Drug allergies
Heart trouble
Dizziness or fainting
Alcohol or drug abuse
High blood pressure
Recent surgery
Angina
Hospitalized
Heart surgery
Pregnant
Asthma
Motion Sickness
Rejected from any activity for any reason
Any medical condition not listed
(please specify):
List all medication you are presently taking:
I certify that the above information is correct to the best of my knowledge:
Signature of Participant: *

Clear
Date *

Month Day Year
Date
I am a minor and my parents have signed below.
Signature of Parent or Guardian:

Clear
Date

Month Day Year
Date
Witness (Name)
Signature

Clear
If yes answered to any of the questions, an additional signature is required. The conditions indicated present no additional or unacceptable risk beyond that which all trainees and divers accept.
Student's / Diver's Signature: *

Clear
Parent or Guardian's Signature:

Clear
Medical History Reaffirmation for Pool / Open Water Training

I certify the above information is still correct to the best of my knowledge.
Signature of Participant *

Clear
Date *

Month Day Year
Date
Signature of Parent or Guardian:

Clear
Date

Month Day Year
Date
Witness (Name)
Signature

Clear
RELEASE OF LIABILITY, WAIVER OF CLAIMS, EXPRESS ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING
EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH DIVING AND RELATED ACTIVITIES
I
Name *

First Name Last Name
do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with Snorkeling, Skin, and/or Scuba diving. I fully understand that these risks can lead to severe injury and even loss of life. I understand that diving operations may be conducted at a site that is remote from a recompression chamber and competent medical assistance. Nevertheless, I choose to proceed even in the absence of a recompression chamber and competent medical assistance. Additionally, I understand that there are also risks associated with dive travel, including, but not limited to the possible injury or loss of life as a result of a dive boat accident, as well as travel to and from dive sites. Despite the potential hazards and dangers associated with the activity of diving, I wish to proceed and I freely accept and expressly assume all risk, dangers, and hazards that may arise from diving activities which could result in personal injury, loss of life, and property damage to me.
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT:
In consideration of being allowed to participate in San Diego Scuba Guide Snorkeling, Skin and/or Scuba Diving activities as well as the use of any of the facilities and the use of the equipment of the below listed releasees, 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 (hereafter referred to as Releasees): San Diego Scuba Guide, Davor Potocnjak NAUI Instructor #51547 and National Association of Underwater Instructors.

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, Skin and/or Scuba diving activities whether caused by active or passive negligence of the releasees or otherwise with the exception of gross negligence. By executing this document, I agree to hold the releasees harmless for any injury or loss of life which may occur to me during Snorkeling, Skin and/or Scuba diving activities, and/or instruction.

3. By entering into this agreement, I am not relying on any oral or written representation 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 California, United States of America.

4. If any provision, section, subsection, clause, or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. 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.
Signature Of Participant *

Clear
Age *
Date Signed *

Month Day Year
Date
FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES to the fullest extent permitted by law.
Signature of Parent or Guardian

Clear
EMERGENCY PHONE#(S)
Please enter a valid phone number.
Date Signed

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Hotel Name
Room
Age *
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
WHO TO CONTACT IN CASE OF AN EMERGENCY:
Name *

First Name Last Name
Relationship *
Phone Number *
Please enter a valid phone number.
INSTRUCTOR/LEADER CONFIRMATION

I HAVE REVIEWED THIS AGREEMENT AND CONFIRM THAT IT HAS BEEN PROPERLY COMPLETED.
Signature Of Instructor/Leader

Clear
Date

Month Day Year
Date
Please note the following excerpt from the “WARRANTIES FOR TRAINING”

Each student shall be required to complete a medical history form at the beginning of training. The beginning of training is defined as the commencement of in-water training activities. A written release for each student must also be completed at the beginning of training.”
HEALTH DECLARATION FORM / COVID-19
Read this statement prior to signing it. You must complete this additional medical questionnaire to enrol 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.

Within the 40 days immediately preceding the date of this Health Declaration Form, have you:
1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR– SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS? *

YES NO
2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)? *

YES NO
3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY? *

YES NO
4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS? *

YES NO
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 San Diego Scuba Guide, its Instructors and Dive Masters 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.
Full Name *
Date *

Month Day Year
Date
Signature *

Clear
Guardian’s Full Name
Date

Month Day Year
Date
Signature

Clear
ADDITIONAL DECLARATIONS / COVID-19
*

I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by San Diego Scuba Guide, its Instructors and Dive Masters, and will take all reasonable preventive steps that may be recommended by, San Diego Scuba Guide, its Instructors and Dive Masters or any relevant public authority. I WILL accept and observe all instructions by San Diego Scuba Guide, its Instructors and Dive Masters 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 ACKNOWLEDGE and ACCEPT that this declaration will be considered as my consent to San Diego Scuba Guide, its Instructors and Dive Masters 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.
Full Name *
Date *

Month Day Year
Date
Signature *

Clear
Guardian’s Full Name
Date

Month Day Year
Date
Signature

Clear
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)
- 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 hospitalized with pulmonar y 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 obser ve strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe / Divers Alert Network
REFERENCES
Diving after COVID-19 pulmonary infection. A position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG

Return to Diving Post COVID-19 - issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA.

The present is a sample of a Health Declaration Form that a dive center 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.
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Medical History Information Form

PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT:

FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION)

WHO TO CONTACT IN CASE OF AN EMERGENCY:

HEALTH DECLARATION FORM / COVID-19

DIVER MEDICAL QUESTIONNAIRE

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

GENERAL RECOMMENDATION

REFERENCES