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Discover Scuba Discover Scuba Come explore the amazing underwater world in the Bradford Woods swimming pool with a maximum depth of 5 ft. Participation requirements: -Minimum age of 12 -PADI Liability release -RSTC Medical History form— To be completed prior to camp with personal physician and submitted during registration. Discover Scuba or Medical History Questions? Bob Kessler [email protected] Non-Agency Disclosure and Acknowledgment Agreement In European Union and European Free Trade Association countries use alternative form. Please read carefully and fill in all blanks before signing. I understand and agree that PADI Members (“Members”), including _______________________________store/resort and/or any individual PADI Instructors and Divemasters associated with the program in which I am participat- ing, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of 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 train- ing 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. I further understand and agree on behalf of myself, my heirs and my estate that in the event of an injury or death during this activity, neither I nor my es- tate shall seek to hold PADI liable for the actions, inactions or negligence of _________________________________________store/resort and/or the instructors and divemasters associated with the activity. Liability Release and Assumption of Risk Agreement In European Union and European Free Trade Association countries use alternative form. Please read carefully and fill in all blanks before signing. I, __________________________________________Participant Name , hereby I also understand that skin diving and scuba diving are physically affirm that I am aware that skin and scuba diving have inherent risks strenuous activities and that I will be exerting myself during this which may result in serious injury or death. program, and that if I am injured as a result of heart attack, panic, I understand that diving with compressed air involves certain inherent hyperventilation, drowning or any other cause, that I expressly as- risks; including but not limited to decompression sickness, embolism sume the risk of said injuries and that I will not hold the Released or other hyperbaric/air expansion injury that require treatment in a Parties responsible for the same. recompression chamber. I further understand that the open water I further state that I am of lawful age and legally competent to sign diving trips which are necessary for training and for certification may this liability release, or that I have acquired the written consent of be conducted at a site that is remote, either by time or distance or my parent or guardian. I understand the terms herein are contractual both, from such a recompression chamber. I still choose to proceed and not a mere recital, and that I have signed this Agreement of my with such instructional dives in spite of the possible absence of a own free act and with the knowledge that I hereby agree to waive recompression chamber in proximity to the dive site. my legal rights. I further agree that if any provision of this Agree- I understand and agree that neither my instructor(s), ment is found to be unenforceable or invalid, that provision shall be ________________________________________________, severed from this Agreement. The remainder of this Agreement will the facility through which I receive my instruction, then be construed as though the unenforceable provision had never _____________________________________________,store/resort been contained herein. nor PADI Americas, Inc., nor its affiliate and subsidiary corporations, I understand and agree that I am not only giving up my right to sue nor any of their respective employees, officers, agents, contractors the Released Parties but also any rights my heirs, assigns, or benefi- or assigns (hereinafter referred to as “Released Parties”) may be ciaries may have to sue the Released Parties resulting from my death. held liable or responsible in any way for any injury, death or other I further represent I have the authority to do so and that my heirs, damages to me, my family, estate, heirs or assigns that may occur assigns, or beneficiaries will be estopped from claiming otherwise as a result of my participation in this diving program or as a result of because of my representations to the Released Parties. the negligence of any party, including the Released Parties, whether I, ____________________________________________,Participant Name passive or active. BY THIS INSTRUMENT AGREE TO EXEMPT AND RELEASE MY In consideration of being allowed to participate in this course (and INSTRUCTORS, __________________________________, optional Adventure Dive), hereinafter referred to as “program,” I THE FACILITY THROUGH WHICH I RECEIVE MY INSTRUCTION, hereby personally assume all risks of this program, whether foreseen _____________________________________________, AND or unforeseen, that may befall me while I am a participant in this PADI AMERICAS, INC., AND ALL RELATED ENTITIES AS DEFINED program including, but not limited to, the academics, confined water ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER and/or open water activities. FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH I further release, exempt and hold harmless said program and Re- HOWEVER CAUSED, INCLUDING, BUT NOT LIMITED TO, THE NEGLI- leased Parties from any claim or lawsuit by me, my family, estate, GENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE. heirs or assigns, arising out of my enrollment and participation in this program including both claims arising during the program or after I receive my certification. I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLDGE- MENT AGREEMENT AND LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS. _________________________________________________________________________________________________________________ __________________________________ Participant’s Signature Date (Day / Month / Year) _________________________________________________________________________________________________________________ __________________________________ Signature of Parent or Guardian (where applicable) Date (Day / Month / Year) Product No. 10072 (Rev. 10/16) Version 4.03 © PADI 2016 MEDICAL STATEMENT Participant Record (Confidential Information) Please read carefully before signing. This is a statement in which you are informed of some potential risks established safety procedures are not followed, however, there are involved in scuba diving and of the conduct required of you during the increased risks. scuba training program. Your signature on this statement is required for To scuba dive safely, you should not be extremely overweight or you to participate in the scuba training program offered out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air by_____________________________________________________and spaces must be normal and healthy. A person with coronary disease, a Instructor current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have _______________________________________________located in the asthma, heart disease, other chronic medical conditions or you are tak- Facility ing medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis city of_______________________, state/province of _______________. thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba Read this statement prior to signing it. You must complete this diving. Improper use of scuba equipment can result in serious injury. You Medical Statement, which includes the medical questionnaire section, to must be thoroughly instructed in its use under direct supervision of a enroll in the scuba training program. If you are a minor, you must have qualified instructor to use it safely. this Statement signed by a parent or guardian. If you have any additional questions regarding this Medical Diving is an exciting and demanding activity. When performed Statement or the Medical Questionnaire section, review them with your correctly, applying correct techniques, it is relatively safe. When instructor before signing. Divers Medical Questionnaire To the Participant: The purpose of this Medical Questionnaire is to find out if you should be exam- Please answer the following questions on your past or present medical history ined by your doctor before participating in recreational diver training. A positive with a YES or NO. If you are not sure, answer YES. If any of these items apply to response to a question does not necessarily disqualify you from diving. A positive you, we must request that you consult with a physician prior to participating in response means that there
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