ENG Formulario Buceo Pura Vida

SCUBA DIVING FORM
PERSONAL DETAILS
Full Name*

First nameLast name
E-mail
example@example.com
Phone Number*
Date of birth*

DíaMesAño
Fecha
Passport / ID card number*
Please confirm which languages you speak:

EnglishSpanishFrenchItalian
Instagram username
During the activity, some photos and videos might be taken. If you want to be tagged on them, please write above your instagram username
Date of birth

Arrival day on the island

Day you fly from Lanzarote (Remember you cannot dive 24 hours before)ID / Passport / NIE

Place of residance
EMERGENCY CONTACT
Name*
Relationship *
Phone Number*
YOUR STAY IN LANZAROTE
Arrival date*

DíaMesAño
When do you / did you arrive in Lanzarote?
Departure date*

DíaMesAño
When are you leaving Lanzarote? Remember you should not dive 24 hours before your flight.
Your accommodation *
Name of your accommodation
Emergency contact (number, name and relationship)
In order to contact this number in case of any need, we need your number, name and relationship.
DETAILS OF THE ACTIVITY
Date of the activity booked with us*

DíaMesAño
Date
What activity have you booked with us?
Have you paid for the activity?
Important! Please note that the activity is considered booked only if you have processed payment.
How did you find about us?
CERTIFICATION AND INSURANCE
Number of dives   number of dives
Last dive      date
Diving Certification   name
Do you have diving computer?
We at Pura Vida lauch 2 or 3 dive trips to Red Sea for our divers annually. Would you be interested that we keep you posted on the dates and travel plans?*

Yes, I would like to join the Pura Vida travel listNo
Diving certification (please add here to make your admin easier upon arrival at the dive center)

Max 5 MB
Cancelof
What languages do you speak?

Only EnglishSpanishFrench
Diving insurance (if you have your insurance please add it here to make your admin easier upon arrival at the dive center)

Cancelof
If you don't have your own insurnace, you can do it online HERE clicking this LINK or at the Diving Center.
Diver Medical | Participant Questionnaire (Confidential)

Diving requires good physical and mental health. There are some medical conditions that can be dangerous during practice of diving, and which are listed below.

Those who have or are predisposed to any of these conditions should be evaluated by a doctor. This Dive Physician Questionnaire provides a basis for determining whether you should seek such an evaluation.

If you have concerns about your scuba fitness that are not represented on this form, please consult your physician before diving.

References to “diving” in this form encompass both Recreational diving with autonomous equipment such as freediving. This form is primarily designed as an initial medical examination for new divers, but is also appropriate for divers receiving continuing education.

For your safety and the safety of others who may dive with you, please answer all questions honestly.

Please complete this questionnaire as a prerequisite for freediving or scuba training.

For women: If you are pregnant, or trying to become pregnant, do not dive.
Medical Statement

All the answers must be NO, otherwise (some answer is positive) mark yes and you will have to undergo a medical examination in Lanzarote.
I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*

NOYES
I am over 45 years of age.*

NOYES
* Select the box(es) that also apply to you. Remember that if you are over 45 years old and check any box we will ask you for a Medical Examination upon arrival

I currently smoke or inhale nicotine through other meansI have a high cholesterol levelI have high blood pressureI have had a relative (first or second degree of consanguinity) who died of sudden death or heart disease or stroke before the age of 50 (including anormal heart disease, coronary artery disease, or cardiomyopathy)
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.*

NOYES
I have had problems with my eyes, ears, or nasal passages/sinuses.*

NOYES
I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*

NOYES
I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*

NOYES
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 or developmental disability.*

NOYES
I have had back problems, hernia, ulcers, or diabetes.*

NOYES
I have had stomach or intestine problems, including recent diarrhea.*

NOYES
I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam).*

NOYES
If you answered NO to the 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below with the date and your signature.
I have answered all questions honestly, and I understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or my failure to disclose any existing or past health conditions.
Data Protection

In the name of the company, we treat the information you provide us with in order to provide them with the requested service, make the invoicing thereof. The data provided will be kept as long as the commercial relationship is maintained or during the years necessary to comply with the legal obligations. The data will not be transferred to third parties except in cases where there is a legal obligation. You have the right to obtain confirmation on whether we are dealing with your personal data at Pura Vida Diving Islas Canarias SL, therefore you have the right to access your personal data, correct inaccurate data or request its deletion when the data is no longer necessary. I also request your authorization to offer products and services related to those requested and to retain you as a customer.

Responsible:

Identity: Pura Vida Diving Islas Canarias SL

NIF: B76249564 Postal

Address: Avenida Islas Canarias 1 CC Punta Limones

Telephone: +34 620281900

E-mail: admin@puravidalanzarotediving.com
Do you agree to transfer your data?*

YESNo
Signature*

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Should be Empty:

SCUBA DIVING FORM

PERSONAL DETAILS

EMERGENCY CONTACT

YOUR STAY IN LANZAROTE

DETAILS OF THE ACTIVITY

CERTIFICATION AND INSURANCE

Medical Statement