Scuba Diving, Snorkelling And Boating Waiver
ADVERTISEMENT
1
2North Stradbroke Island Operations Pty Ltd
MEDICAL DECLARATION
ABN: 36 107 714 974
132 Dickson Way, Point Lookout, Qld. 4183
Phone: (07) 3409 8888, Fax: (07) 3409 8588
I,
____________________________________________________, declare that I am in good mental and
(Print Name)
.au
physical fitness for scuba diving, snorkelling and boating, and that I am not under the influence of alcohol, nor am I
under the influence of any drugs that are contradictory to scuba diving or snorkelling.
SCUBA DIVING, SNORKELLING AND BOATING WAIVER 8.DOC
I fully understand that asthma, epilepsy, any recent surgery, most prescription medications, heavy colds and flu
•
within the last 10 days, are reason not to dive. I further fully understand that recent alcohol consumption and use
PERSONAL DETAILS
of recreational drugs also are reasons not to dive. I understand that the above mentioned conditions and practices
Name ________________________________________________ Birth Date _________________Age _______
contribute to factors which can lead to decompression illness or embolisms even when all scuba diving practices
First
Initial
Last
Day/Month/Year
are performed correctly and within the limits of recreational no-decompression diving.
M ale
F emale
Occupation __________________________________________________________Sex:
If I am taking medication, I declare that I have seen a physician and have approval to scuba dive/snorkel while
•
under the influence of the medication/drugs.
Mailing Address________________________________________________________________________________
I understand that skin and scuba diving are physically strenuous activities and that I will be exerting myself
•
City __________________________________________ State/Province/Region _____________________________
during this activity and that if I am injured as a result of heart attack, panic, hyperventilation, etc., that I assume
the risk of said injuries and that I will not hold the Released Parties responsible for the same.
Country ____________________________________________ Zip/Postal Code _____________________________
I understand that concealment of any medical or physical condition might put my life or health or the life or
•
Home Phone (
) _________________________ Mobile ____________________________________________
health of others at risk.
I have been advised that the activities may involve strenuous physical activity even in calm water and that older
•
Email _________________________________________________________________________________________
people are at an increased risk of death and injury due to a higher incidence of medical conditions made worse by
Emergency Contact Person __________________________________ Relationship _________________________
physical exertion, such as heart disease and stroke.
First
Last
I have been advised to tell the dive co-ordinator, if I have any concerns about medical conditions, fitness levels,
•
Emergency Contact - Phone (
) __________________________, and Mobile____________________________
and swimming ability.
I agree that if I suffer from any medical condition from the time when this form is executed by me, to the time I
•
SNORKEL EXPERIENCE
WARNING BOX
undertake the activities, I will fully disclose the same to Manta Lodge and Scuba Centre and will execute an
Do you require a personal flotation device?
Yes
No
VERIFY DIVE
updated medical information form if and when required.
Can you swim?
Yes
No
CERTIFICATION
Manta Lodge YHA and Scuba Centre reserves the right in its absolute unfettered discretion, to refuse to allow me
•
to participate in the activities or to cancel any activities at their discretion, at any time, in the interest of safety or
Have you snorkelled before?
Yes
No
other factors.
______________
DIVE QUALIFICATION
STAFF SIGN
I have read the above statements and have had any questions answered to my satisfaction. I further state that I am of
Certifying Organisation:
PADI, ______ Cert No____________________
lawful age and legally competent to sign this declaration, or that I have obtained the written consent of my parent or
Discover Scuba Experience,
Junior Open Water,
Open Water Diver,
ADV Open Water,
guardian.
Rescue Diver,
Dive Master,
Instructor, Other_____________________________
__________________________________________
________________________
DIVE EXPERIENCE
Participant’s Signature
Date (Day/Month/Year)
Expert
Proficient
Competent
Beginner No of Logged Dives: ________
__________________________________________
________________________
Certified for deep-water 18-30m / 60-100ft
Yes
No
Signature of Parent or Guardian (if Participant under 18 years)
Date (Day/Month/Year)
Have you dived in the ocean before?
Yes
No
DIVE GEAR HIRE
Have you dived in a current before?
Yes
No
STRADBROKE FLYER
Last Dive?
Within 6 months
Within 1 years
A Refresher Course is needed. If you
Gold Cats Return ticket
$15
I,
______________________________________________, the
haven't been diving for a while and your dive skills aren't as good as they should be we strongly
(Print Name)
RENTER will not hold the Released Parties responsible for my failure to
recommend that you do a Refresher Course before you go diving.
inspect the equipment prior to diving or if I choose to dive with equipment
GEAR HIRE
PADI “Flying After Diving” guidelines say that you should not go to altitude (fly) within 12 hours of
that may not be functioning properly. This AGREEMENT is a release of
BCD
$22
my rights and the rights of my heirs, assigns or beneficiaries to sue for
completing a single dive or 18 hours when doing multiple dives (where possible wait 24 hours). Do you
Regulator, w/Computer
$25
injuries or death resulting from the rental and/or use of this equipment. I
intend on flying within 24hrs from the last dive of this trip?
Yes
No
Wrist Dive Computer
$20
personally assume all risks of skin and/or scuba diving, whether foreseen or
Wetsuit
$15
INSTRUCTOR PRO CHECK (A, B)
unforeseen, related in any way to the rental and/or use of this equipment.
Mask, w/Snorkel
$8
I agree to reimburse the Dive Centre for the loss or breakage of any and all
Please Print and Attach PADI
A. Authorised to teach?
Yes
No
(Attach current teaching status)
Fins
$8
equipment at the current replacement value. I agree to return the equipment
Pro Check or equivalent,
B. Professional Liability Insurance is current?
Yes
No
Booties
$8
in clean condition and to pay a cleaning fee if not returned cleaned.
Authority to teach & Insurance
Course being conducted ___________________________________
Total $________
No of Students _______ Note: ______________________________
__________________________________ ____________
I the Instructor understand and take full responsibility to adhere to all applicable standards and
Renter’s Signature
Date (Day/Month/Year)
__________________________________ ____________
procedures being conducted on this course.
________________________________________
___________________
Instructor Signature
Date (Day/Month/Year)
Signature of Parent or Guardian (if Renter is under 18 years)
Date (Day/Month/Year)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal