Discover Scuba Diving Required Information Required First name Optional Middle Initial Required Last name Required Date of DSD from our email Required Time of DSD from our email Required Email Required Gender MaleFemale Required Date of birth (dd/mm/yyyy) 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 Required Height in feet & inches Required UK Chest/Dress Size Required UK Waist Size Required UK Shoe Size PADI Discover Scuba® Diving Participant Statement Read the following paragraphs carefully. This statement, which includes a Medical Questionnaire, a Liability Release and Assumption of Risk Agreement (Statement of Risks and Liability), Non-Agency Disclosure and Acknowledgment and the Discover Scuba Diving Knowledge and Safety Review, informs you of some potential risks involved in scuba diving and of the conduct required of you during the PADI Discover Scuba Diving program. If you are a minor, your parent or guardian must read this Guide and sign below. You will also need to learn important safety rules regarding breathing and equalization while scuba diving from the PADI Professional. Scuba diving and the use of scuba equipment without proper supervision or instruction can result in serious injury or death. You must be instructed in its use under the direct supervision of a qualified instructor. PADI Medical Questionnaire Scuba diving is an exciting and demanding activity. To scuba dive you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs, should not dive. If taking medication, consult your doctor before participating in this program. The purpose of the Medical Questionnaire is to find out if you should be examined by a physician before participating in recreational scuba diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of a physician. Please answer the following questions on your past and present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your PADI Professional will supply you with a PADI Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to a physician. Do you currently have an ear infection?---NOYES Do you have a history of ear disease, hearing loss or problems with balance?---NOYES Do you have a history of ear or sinus surgery?---NOYES Are you currently suffering from a cold, congestion, sinusitis or bronchitis?---NOYES Do you have a history of respiratory problems, severe attacks of hayfever or allergies, or lung disease?---NOYES Have you had a collapsed lung (pneumothorax) or history of chest surgery?---NOYES Do you have active asthma or history of emphysema or tuberculosis?---NOYES Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities?---NOYES Do you have behavioral health, mental or psychological problems or a nervous system disorder?---NOYES Are you or could you be pregnant?---NOYES Do you have a history of colostomy?---NOYES Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?---NOYES Do you have a history of high blood pressure, angina, or take medication to control blood pressure?---NOYES Are you over 45 and have a family history of heart attack or stroke?---NOYES Do you have a history of bleeding or other blood disorders?---NOYES Do you have a history of diabetes?---NOYES Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?---NOYES Do you have a history of back, arm or leg problems following an injury, fracture or surgery?---NOYES Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?---NOYES Non-Agency Disclosure and Acknowledgment Agreement I understand and agree that PADI Members (“Members”), including Scuba Pursuits 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. 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, Scuba Pursuits Instructors, DSD Leaders & Divemasters, nor the facility through which this programme is conducted, Scuba Pursuits, 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, Scuba Pursuits Instructors, DSD Leaders & Divemasters, the facility through which this programme is offered, Scuba Pursuits, 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 TICKING THE BOX BELOW AS MY DIGITAL SIGNATURE TO THESE STATEMENTS. Under 18? Your parent or guardian must enter their name and relationship below, and also tick the agreement box for you under Required below Applicable? Name Applicable? Relationship ---FatherMotherGuardian Required I am 18 or older, and I hereby tick the box below as my digital signature and agreement to these statementsI agree Hit the 'Send' button below and then check your inbox and spam folder for our auto reply email containing the link to the final required form To use CAPTCHA, you need Really Simple CAPTCHA plugin installed.