Statement of Risk and Liability/Medical Form

Name*

FIRST NAMELAST NAME

PLACE OF BIRTH*

DATE OF BIRTH*

Address*

ADDRESS

Street Address Line 2

STATE

EMAIL*

esempio@esempio.com

PHONE*

Area codePhone number

DIVING LICENSE (level and association)*

LAST DIVE*

Date of your last dive

TOTAL N. OF DIVES*

Non-Agency Disclosure and Acknowledgment Agreement

I understand and agree that PADI Members ("Members"), including BULLY DIVING S.S.D.r.l. 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 EMEA Ltd., 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.

Statement of Risk and Liability

This is a statement in which you are informed of the risks of skin and scuba diving. The statement also sets out the circumstances in which you participate in the diving programme at your own risk. The statement is valid for the whole current year.

Your signature on this statement is required as proof that you have received and read this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then please discuss it with your instructor. If you are a minor, this form must also be signed by a parent or guardian.

Warning

Skin and scuba diving have inherent risks which may result in serious injury or death. Diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. Open water diving trips that 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. Skin and scuba diving are physically strenuous activities and you will be exerting yourself during this diving programme. You must advise truthfully and fully inform the dive professionals and the facility through which this programme is offered of your medical history.

Acceptance of Risk

I understand and agree that neither the dive professionals conducting this programme, nor the facility through which this programme is conducted, BULLY DIVING S.S.D.r.l., nor PADI EMEA Ltd., nor PADI Americas, Inc. nor their affiliate or subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns accept any responsibility for any death, injury or other loss suffered by me to the extent that it result from my own conduct or any matter or condition under my control that amounts to my own contributory negligence.

In the absence of any negligence or other breach of duty by the dive professionals conducting this programme, the facility through which this programme is offered, BULLY DIVING S.S.D.r.l., PADI EMEA Ltd., PADI Americas, Inc. and all parties referred to above, my participation in this diving programme is entirely at my own risk.

I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT AND STATEMENT OF RISK AND LIABILITY BY READING BOTH BEFORE SIGNING THESE STATEMENTS.

Date*

Participant Signature (Signature of Parent/Guardian where applicable)*

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,

NAME*

FirstLast

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.

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 specifically trained to do so.

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.

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.

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.

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 metres/60 feet per minute. Be a SAFE diver - Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer.

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

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.

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

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

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.

Participant Signature (Signature of Parent/Guardian where applicable)*

Date*

AUTHORIZATION

I authorize, according to the law 196/2003, the treatment of the transmitted personal data. I authorize BULLY DIVING S.S.D.r.l. to use my personal data for the sending of any material information, advertising or promotional material according to Law 675/96.

Participant Signature (Signature of Parent/Guardian where applicable)*

Date*

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.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.*

Yes -> you'll have to fill in the 'BOX A' in the form you'll receive via e-mailNo

2. I am over 45 years of age.*

Yes -> you'll have to fill in the 'BOX B' in the form you'll receive via e-mailNo

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.*

Yes -> a medical certificate is requiredNo

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

Yes -> you'll have to fill in the 'BOX C' in the form you'll receive via e-mailNo

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

Yes -> a medical certificate is requiredNo

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

Yes -> you'll have to fill in the 'BOX D' in the form you'll receive via e-mailNo

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 or developmental disability.*

Yes -> you'll have to fill in the 'BOX E' in the form you'll receive via e-mailNo

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

Yes -> you'll have to fill in the 'BOX F' in the form you'll receive via e-mailNo

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

Yes -> you'll have to fill in the 'BOX G' in the form you'll receive via e-mailNo

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

Yes -> a medical certificate is requiredNo

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.

Participant Name (Print)*

First and Last Name

Birthdate (dd/mm/yyyy)*

Date of Birth

Facility Name (Print)

Participant Signature (or, if a minor, participant's parent/guardian signature required)*

Date (dd/mm/yyyy)*

ATTENTION PLEASE!!!

If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2 (see the form you will receive via e-mail), please read and agree to the statement above by signing and dating it AND take all three pages (see e-mail) of this form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.