RELEASE OF LIABILITY, WAIVER OF CLAIMS, AND EXPRESS ASSUMPTION OF RISK AGREEMENT

EXPRESS ASSUMPTION OF RISK ASSOCIATED WITH SNORKELING, APNEA DIVING, SCUBA DIVING, FIRST AID, AND RELATED ACTIVITIES

hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks associated with Snorkeling, Apnea Diving, SCUBA Diving, First Aid, and instrucCon related thereto (“Diving AcCviCes”). I fully understand that these hazards and risks can lead to severe injury and even loss of life. I understand that Snorkeling, Apnea Diving, SCUBA Diving, and First Aid acCviCes 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. AddiConally, I understand that there are also hazards and risks associated with Snorkeling, Apnea Diving, SCUBA Diving, First Aid, and related travel, including, but not limited to the possible injury or loss of life as a result of a vessel accident, being hit by a vessel while in or under the water, while boarding, disembarking, exiCng and/or re boarding the vessel to begin or end diving acCviCes, equipment failure, user error, as well as during travel to and from dive sites. Despite the potenCal hazards and risks associated with Snorkeling, Apnea Diving SCUBA Diving, First Aid acCviCes, and related acCviCes which can include but are not limited to, aquaCc life encounters, currents, waves, barotraumas (pressure change related injuries), sudden loss of visibility, entrapment underwater in wrecks, caves, vegetaCon, fishing line, fishing nets or debris, I wish to proceed and I freely accept and expressly assume all hazards and risks, that may arise from Snorkeling, Apnea Diving, SCUBA Diving, First Aid acCviCes, and related acCviCes which could result in personal injury, loss of life and property damage to me.

In consideration of being allowed to participate in Snorkeling, Apnea Diving, SCUBA Diving, and First Aid activities as well as the use of any of the faciliCes and the use of the equipment of the below listed persons or enCCes, I hereby agree as follows:

1. TO WAIVE AND RELEASE ANY AND ALL CLAIMS based upon negligence, acCve or passive with the excepCon of intenConal, wanton or willful misconduct that I may have in the future against any of the following named persons or enCCes (hereina[er re ferred to as Releasees); San Diego Scuba Guide, Davor Potocnjak NAUI Instructor #51547 and NaConal AssociaCon of Unde rwater Instructors, Inc. (NAUI).

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, Apnea Diving, SCUBA Diving, First Aid activities, and related activities whether caused by active or passive negligence of the Releasees or otherwise with the exception of gross negligence. By executing this Agreement, I agree to hold the Releasees harmless for any injury or loss of life which may occur to me during Snorkeling, Apnea Diving, SCUBA Diving, and First Aid activities and/or instruction, and any and all future courses of instruction, programs and Snorkeling, Apnea Diving, SCUBA Diving, and First Aid related travel I undertake.

3. I fully understand that Snorkeling, Apnea Diving, SCUBA Diving, and First Aid related acCviCes are physically strenuous and I will be exerCng myself during this course of instrucCon. I understand and agree that if I am injured or killed as a result of heart a]ack, panic, hypervenClaCon, oxygen toxicity, hypoxia, narcosis, aquaCc life encounters, drowning or any other cause, that I expressly assume the risk of these injuries and/or a]ended death and that I will not hold the Releasees included in this Agreement responsible in any other way.

4. By entering into this Agreement, I am not relying on any oral or wri]en representaCon 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 Florida, United States of America.

5. If any provision, section, subsection, clause or phrase of this Agreement is found to be unenforceable or invalid, that portion shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable portion had never been contained in the Agreement.The English language version of this document shall be controlling in all respects and shall prevail in case of any inconsistencies with translated versions.

I fully understand that the terms of this Agreement are contractual in nature and not a mere recital. I further state by way of my signature I have signed this Agreement of my own free act. 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.

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.

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.

 

*If you answered YES to questions 3, 5 or 10 above OR to any of the questions on page 2, please read and agree to the statement above by signing and dating it AND take all three pages 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.

*Physician’s medical evaluation required (see page 1).

Diver Medical | Medical Examiner’s Evaluation Form

The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba diving or freediving

training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas rele-

vant to your patient as part of your evaluation.

Created by the Diver Medical Screen Committee in association with the following bodies:
The Undersea & Hyperbaric Medical Society
DAN (US)
DAN Europe
Hyperbaric Medicine Division, University of California, San Diego