Scuba San Diego Release Liability Forms

I, (PRINT PARTICIPANT LEGAL NAME) *

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 instruction related thereto (“Diving Activities”). 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 activities 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 are compression chamber and competent medical assistance. Additionally, 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, exiting and/or reboarding the vessel to begin or end diving activities, equipment failure, user error, as well as during travel to and from dive sites. Despite the potential hazards and risks associated with Snorkeling, Apnea Diving SCUBA Diving, First Aid activities, and related activities which can include but are not limited to, aquatic life encounters, currents, waves, barotraumas (pressure change related injuries), sudden loss of visibility, entrapment underwater in wrecks, caves, vegetation, 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 activities, and related activities which could result in personal injury, loss of life and property damage to me.

RELEASE OF LIABILITY AND WAIVER OF CLAIMS AGREEMENT:
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 facilities and the use of the equipment of the below listed persons or entities, 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 (hereinafter referred to as Releasees); National Association of Underwater Instructors, Inc. (NAUI) and subsidiary companies: Instructor/s and Leader/s) Rodney M. Watkins, his assigns, representatives and contractors(Facility/ies) Scuba San Diego Inc.(Others) City of San Diego, Department of Parks and Recreation

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 activities are physically strenuous and I will be exerting myself during this course of instruction. I understand and agree that if I am injured or killed as a result of heart a]ack, panic, hyperventilation, oxygen toxicity, hypoxia, narcosis, aquatic 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 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 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.*

Date*

Date

Witness (Printed Name)

Witness Signature

Signature of Parent OR Guardian If Participant Is a Minor, and by their signature they, on my behalf release all claims that both they and I have. Signature of Parent OR Guardian:

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 (Go to box A)No

2. I am over 45 years of age.*

Yes (Go to box B)No

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), ORI have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months*

Yes (Physician’s medical evaluation required)No

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

Yes (Go to box C)No

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

Yes (Physician’s medical evaluation required)No

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

Yes (Go to box D)No

7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personalitydisorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmentaldisability.*

Yes (Go to box E)No

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

Yes (Go to box F)No

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

Yes (Go to box G)No

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

Yes (Physician’s medical evaluation required)No

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

Date*

Date

Name*

First NameLast Name

Birthdate*

Date

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.

Diver Medical | Participant Questionnaire Continued

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.

Yes (Physician’s medical evaluation required)No

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.

Yes (Physician’s medical evaluation required)No

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.

Yes (Physician’s medical evaluation required)No

Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.

Yes (Physician’s medical evaluation required)No

Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.

Yes (Physician’s medical evaluation required)No

I currently smoke or inhale nicotine by other means

Yes (Physician’s medical evaluation required)No

I have a high cholesterol level

Yes (Physician’s medical evaluation required)No

I have high blood pressure

Yes (Physician’s medical evaluation required)No

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 (Physician’s medical evaluation required)No

Sinus surgery within the last 6 months.

Yes (Physician’s medical evaluation required)No

Ear disease or ear surgery, hearing loss, or problems with balance.

Yes (Physician’s medical evaluation required)No

Recurrent sinusitis within the past 12 months

Yes (Physician’s medical evaluation required)No

Eye surgery within the past 3 months.

Yes (Physician’s medical evaluation required)No

Head injury with loss of consciousness within the past 5 years.

Yes (Physician’s medical evaluation required)No

Persistent neurologic injury or disease.

Yes (Physician’s medical evaluation required)No

Recurring migraine headaches within the past 12 months, or take medications to prevent them.

Yes (Physician’s medical evaluation required)No

Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.

Yes (Physician’s medical evaluation required)No

Epilepsy, seizures, or convulsions, OR take medications to prevent them.

Yes (Physician’s medical evaluation required)No

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.

Yes (Physician’s medical evaluation required)No

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.

Yes (Physician’s medical evaluation required)No

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.

Yes (Physician’s medical evaluation required)No

An addiction to drugs or alcohol requiring treatment within the last 5 years.

Yes (Physician’s medical evaluation required)No

Recurrent back problems in the last 6 months that limit my everyday activity.

Yes (Physician’s medical evaluation required)No

Back or spinal surgery within the last 12 months.

Yes (Physician’s medical evaluation required)No

Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.

Yes (Physician’s medical evaluation required)No

An uncorrected hernia that limits my physical abilities.

Yes (Physician’s medical evaluation required)No

Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Yes (Physician’s medical evaluation required)No

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.

Yes (Physician’s medical evaluation required)No

Dehydration requiring medical intervention within the last 7 days.

Yes (Physician’s medical evaluation required)No

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.

Yes (Physician’s medical evaluation required)No

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD)

Yes (Physician’s medical evaluation required)No

Active or uncontrolled ulcerative colitis or Crohn’s disease.

Yes (Physician’s medical evaluation required)No

Bariatric surgery within the last 12 months.

Yes (Physician’s medical evaluation required)No

Diver Medical | Medical Examiner’s Evaluation Form
TO BE FILLED OUT BY A PHYSICIAN IF REQUIRED FOR PARTICIPATION

Name

First NameLast Name

Birthdate

Date

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.

Evaluation Result

Approved – I find no conditions that I consider incompatible with recreational scuba diving or freediving.Not approved – I find conditions that I consider incompatible with recreational scuba diving or freediving.

Signature

Date

Medical Examiner’s Name

Clinical Degrees/Credentials

Clinic/Hospital

Address

Phone Number

Email Address

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

RELEASE OF LIABILITY, WAIVER OF CLAIMS, AND EXPRESS ASSUMPTION OF RISK AGREEMENTPLEASE READ AND BE CERTAIN YOU UNDERSTAND THE IMPLICATIONS OF SIGNING THIS RELEASE

Box A - I have/have had

BOX B – I AM OVER 45 YEARS OF AGE AND:

BOX C – I HAVE/HAVE HAD:

BOX D – I HAVE/HAVE HAD:

BOX E – I HAVE/HAVE HAD:

BOX F – I HAVE/HAVE HAD:

BOX G – I HAVE/HAVE HAD: