Checkin

GENERAL LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK
Directions: Please fill in all the blanks. Once done, please press "Preview PDF" at the bottom of the form and read everything before signing and submitting.
For (specify Course or Specialty) training program. Or unguided.*
Training agency (For the course)
Facility name
Instructor name*
Training agency (Your)
Level of certification*
Certified diver since
Diving for (in years)
Number of dives
Maximum depth (meter)
Date of last dive

Before Signing

Please press "Preview PDF" at the bottom of the form and read everything before signing and submitting.
Date (arrival at Dive Center)*

JourMoisAnnée
Date
Signature Student/Participant

Clear
Signature of Parents or Guardians (when applicable)

Clear
Should be Empty:

	YES	NO
Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator) or a pneumothorax (collapsed lung).
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.
A diagnosis of COVID-19.

	YES	NO
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).

	YES	NO
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.

	YES	NO
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.

	YES	NO
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 or special accommodation.
An addiction to drugs or alcohol requiring treatment within the last 5 years..

PERSONAL INFORMATION

	YES	NO
Recurrent back problems in the last 6 months that limit my everyday activity.
Back or spinal surgery within the last 12 months.
Diabetes, either drug 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.

	YES	NO
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.