PADI Bubblemaker Statement

Participant Record (Please read carefully, fill in all blanks, and sign and date below.)

Participant Name
   
Street Address
   
City
   
State
   
Zip
   
Email
   
Day Phone
Eve or Cell Phone

Sex
   
Age
   
Date of Birth (Day-Month-Year)
   

EMERGENCY CONTACT:
Name
   
Relationship
   
Primary Phone
   
Alternate Phone
   
 

MEDICAL QUESTIONNAIRE

To the participant and parent: 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.
___ Yes ___ No   I am currently suffering from a cold or congestion.
___ Yes ___ No   I have a history of respiratory problems or disease.
___ Yes ___ No   I have had asthma, emphysema or tuberculosis.
___ Yes ___ No   I currently have an ear infection.
___ Yes ___ No   I have recurrent ear problems, ear disease or surgery.
___ Yes ___ No   I have a history of sinus problems.
___ Yes ___ No   I have had problems equalizing (popping) my ears with airplane or mountain travel.
___ Yes ___ No   I am diabetic.
___ Yes ___ No   I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).
___ Yes ___ No   I have a history of seizures, dizziness or fainting.
___ Yes ___ No   I have a nervous system disorder.
___ Yes ___ No   I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).
___ Yes ___ No   I have recurrent back problems, history of back or spinal surgery.
___ Yes ___ No   I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).
___ Yes ___ No   I have recently had an operation or illness.
___ Yes ___ No   I am under the care of a physician or have a chronic illness.
       

BUBBLEMAKER ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT

I/we, ________________________________(parent/guardian), and  ____________________________________, participant, hereby affirm that we are aware of and understand there are inherent hazards associated with scuba diving which may result in serious injury or death.

We understand there are certain risks associated with aquatic activities conducted in and around a swimming pool or confined water dive site, and we expressly assume the risk of said injuries.

We understand that diving with compressed air involves certain inherent risks and my child will be exposed to these risks. Decompression sickness, embolism or other hyperbaric injuries can occur which require treatment in a recompression chamber. We further understand that this activity may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. We still choose to proceed with this activity in spite of the absence of a recompression chamber in proximity to the activity site.

We understand and agree that neither the dive professionals conducting this activity, nor the facility through which this activity is conducted, Huron Scuba, Snorkel and Adventure Travel Inc., nor International PADI, Inc., nor any of their respective employees, officers, agents or assigns (hereinafter referred to as "Released Parties") may be held liable or responsible in any way for any injury, death or other damages to my child, me, my family, our heirs or assigns that may occur as a result of my child's participation in this activity or as a result of the negligence of any party, including the Released Parties, whether passive or active.

We further understand that scuba diving is a physically strenuous activity and that my child will be exerting him/herself during this activity and that if my child is injured as a result of heart attack, panic, hyperventilation, etc., that we expressly assume the risk of said injuries to my child. We affirm that we will not hold the above listed individuals or companies responsible for the same.

In consideration of my child being allowed to participate in this activity we hereby personally assume all risks in connection with the activity for any harm, injury or damage that may befall my child while participating in the activity, including all risks connected therewith, whether foreseen or unforeseen.

We further release and hold harmless said activity and the Released Parties from any claim or lawsuit by my child, me, or my family, or our estate, heirs or assigns, arising out of my child's participation in this activity.

We understand and agree this Release is divisible, and any portion herein held to be in violation of any applicable statues or regulations or any governmental agency having jurisdiction shall affect only that portion held to be invalid or inoperative, and the remaining portions of this Release shall remain in full force and effect.

I further state that I am of lawful age and legally competent to sign this Assumption of Risk and Liability Release Agreement, and as the parent am providing written consent for the participation of my child.

We understand that the terms herein are contractual and not a mere recital and that we have signed this release of our own free act. 

I, ________________________________, PARENT/GUARDIAN, AND  ____________________________________, PARTICIPANT, BY THIS INSTRUMENT DO EXEMPT AND RELEASE THE DIVE PROFESSIONALS CONDUCTING THIS ACTIVITY, THE FACILITY THROUGH WHICH THIS ACTIVITY IS CONDUCTED, AND INTERNATIONAL PADI, INC., AND ALL RELATED ENTITIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH, HOWEVER CAUSED, INCLUDING BUT NOT LIMITED TO THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE.

WE HAVE FULLY INFORMED OURSELVES OF THE CONTENTS OF THIS ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF, MY CHILD, AND OUR HEIRS.

________________________________ ________________________________ ______________________
Parent/Guardian Name Parent/Guardian Signature Date (Day/Month/Year)
 
________________________________ ________________________________ ______________________
Participant/Minor Name Participant/Minor Signature Date (Day/Month/Year)


Product No. 10268  (3/05) Version 1.1 © International PADI, Inc. 2005