Bubblemaker Required Information PADI BUBBLEMAKER STATEMENT (PADI International Ltd) Required First name Optional Middle Initial Required Last name Required Date of Bubblemaker session from our email or confirmed by calling 07928 562916 ---25/05/201908/06/201922/06/201906/07/201920/07/201920/07/201927/07/201903/08/201910/08/201917/08/201924/08/201931/08/201914/09/201928/09/201912/10/201926/10/201909/11/201923/11/201907/12/201921/12/2019 Required Time of Bubblemaker session from our email or confirmed by calling 07928 562916 ---2:15-4:15pm2:40-4:40pm3:20-5:20pm5:30-7:30pm6:10-8:10pm6:50-8:50pm Required Email of parent/guardian Required Gender MaleFemale Required Date of birth (dd/mm/yyyy) Required Age on Bubblemaker date Required Address Required City or town Required County Required Post code Fixed Field. Please call 01733 351288 if your address is not in the UK Country UK Required Mobile Phone of parent/guardian Required Height in feet & inches Required UK Chest/Dress Size Required UK Waist Size Required UK Shoe Size Medical Questionnaire To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant’s past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician. I am currently suffering from a cold or congestion.---NOYES I have a history of respiratory problems or disease.---NOYES I have had asthma, emphysema or tuberculosis.---NOYES I currently have an ear infection.---NOYES I have recurrent ear problems, ear disease or surgery.---NOYES I have a history of sinus problems.---NOYES I have had problems equalizing (popping) my ears with airplane or mountain travel.---NOYES I am diabetic.---NOYES I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).---NOYES I have a history of seizures, dizziness or fainting.---NOYES I have a nervous system disorder.---NOYES I have behavioural health, mental or psychological disorders (panic attack, fear of closed or open spaces).---NOYES I have recurrent back problems, history of back or spinal surgery.---NOYES I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).---NOYES I have recently had an operation or illness.---NOYES I am under the care of a physician or have a chronic illness.---NOYES BUBBLEMAKER STATEMENT OF RISKS AND LIABILITY Please read carefully and fill in all blanks before signing. 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 your child participates in the diving programme at your child’s own risk. Your signature on this statement is required as proof that you and your child 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 child’s instructor. 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 and your child will be exposed to these risks. This programme may be conducted at a site which is remote, either by time or distance or both, from such a recompression chamber. Skin and scuba diving are physically strenuous activities and your child will be exerting themselves 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 child’s medical history. EXCLUSION OF LIABILITY I understand and agree that neither the dive professionals conducting this programme, Scuba Pursuits Instructors, DSD Leaders & Divemasters, nor the facility through which this programme is conducted, Scuba Pursuits S-24181, nor PADI International Ltd., nor PADI Americas, Inc., nor their affiliate or subsidiary corporations, nor any of their respective employees, officers, agents or assigns (hereinafter referred to as “Released Parties”) accept any responsibility for any death, injury or other loss suffered or caused by me or resulting 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, Scuba Pursuits Instructors, DSD Leaders & Divemasters, the facility through which this programme is offered, Scuba Pursuits S-24181, PADI International Ltd., PADI Americas, Inc., and all related entities and released parties as defined above, my participation in this diving programme is entirely at my own risk. I acknowledge receipt of this Statement and have read all of the terms before signing this Statement. Your parent or guardian must enter their name and relationship below, and also tick the agreement box for you under Required below Required Parent or Guardian Name Required? Parent or Guardian Relationship ---FatherMotherGuardian Required I am 18 or older, and I hereby tick the box below as my parent/guardian digital signature and agreement to this statementI agree After you hit the 'Send' button below You'll receive confirmation that ... 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