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DISCOVER SCUBA DIVING REGISTRATION FORM
For Headquarters Use:
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DIRECT
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Skills Completed:
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Registration:
Yes
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MASK & SNORKEL
SCOUT
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F II
FI
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FINS
34-35
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38-39
40-41
42-43
44-45
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3XS
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XS-S
S
M-L
XL
2XL
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WETSUIT (Jacket/L.J)
Kids S
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Kids L
0
1
2
3
4
5
6
7
8
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BCD JACKET
XXXS
XXS
XS
S
M
L
XL
XXL
XXXL
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TANK
3L
6L
10L
12L
15L
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CAMERA
Yes
No
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SD CARD
Yes
No
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SD CART SIZE
8GB
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STUDENT INFORMATION PLEASE PRINT CLEARLY - IN CAPITAL - ALL INFORMATION BELOW
Name
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Date of birth
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Participant Signature
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Father's name
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Address
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City
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State
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Country
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Code
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Telephone
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Email
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Occupation
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Age
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Sex
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Facebook
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How did you find out about us - Please Choose
How did you find out about us - Please Choose
Internet
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Please specify
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To continue your Discover Diving experience, you must complete this review under the direction of your PADI Professional BEFORE getting in the water. Check the appropriate box in response to each question
Upon completing this experience, I will be qualifies to dive independently without a certified professional guiding me.
T
F
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To equalize my ears and sinus air space during descent, I will need to blow gently against pinced nostrilis
T
F
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I should equalize every meter/few feet while descending
T
F
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If i have discomfort in my ears or sinuses during descent, I should continue downward
T
F
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Underwater, I should breathe slowly, deeply, continuosly and never hold my breath
T
F
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I should add to my buoyancy control device (BCD) to float at the surface
T
F
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My air gauge indicates how much air i have in my cylinder and i must look at it often, and whenever my instruct asks me to.
T
F
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I should not touch, tease or harass an underwater organism since I may harm it or it may harm me.
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F
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I should stay close to the PADI Professional during my Discover Scuba Diving experience and signal if something is wrong
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F
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Participant Statement : I have had this Review explained to me and I now understand any questions I may have answered incorrectly. I acknowledge and accept that these practices are intended to increase my safety and comfort during the experience
PADI Discover Scuba Diving Participant Statement Please read the following paragraphs carefully and fill in all blanks before signing, This statement, which includes a Medical Questionnaire, Discover Scuba Diving Safe Practices Statement and a Statement of Risks and Liability, informs you of some potential risks involved in scuba diving and of the conduct required of you during the PADI Discover Scuba Diving programme. Your signature is required to participate in the programme. lf you are a minor, you must have the Participant Statement (which includes and acknowledges the Medical Questionnaire, the Discover Scuba Diving Safe Practices and the Statement of Risks and Liability) signed by your parent or guardian. You will also need to learn from the instructor the important safety rules regarding breathing and equalisation while scuba diving. lmproper use of scuba equipment can result in serious injury or death. You must be thoroughly instructed in its use under the direct supervision of a qualified instructor to use it safely. PADI Medical Questionnaire Scuba diving is an exciting and demanding activity. To scuba dive safely, 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. lf taking medication, consult your doctor before participating in this programme. The purpose of this medical history questionnaire is to find out if a doctor should examine you 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 pre-existing 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. lf you are not sure, answer YES. lf any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your Instructor 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?
Y
N
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Do you have a history of ear disease, hearing loss or problems with balance?
Y
N
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Do you have a history of ear or sinus surgery?
Y
N
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Are you currently suffering from a cold, congestion, sinusitis or bronchitis?
Y
N
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Do you have a history of respiratory problems, severe attacks of hay fever or allergies, or lung disease?
Y
N
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Have you had a collapsed lung (pneumothorax) or history of chest surgery
Y
N
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Do you have active asthma or history of emphysema or tuberculosis?
Y
N
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Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities?
Y
N
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Do you have behavioural health problems or a nervous system disorder?
Y
F
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Are you or could you be pregnant?
Y
N
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Do you have a history of colostomy?
Y
N
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Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?
Y
N
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Do you have a history of high blood pressure, angina, or take medication to control blood pressure?
Y
N
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Are you over 45 and have a family history of heart attack or stroke?
Y
N
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Do you have a history of bleeding or other blood disorders?
Y
N
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Do you have a history of diabetes?
Y
N
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Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?
Y
N
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Do you have a history of back, arm or leg problems following an injury, fracture or surgery?
Y
N
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Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?
Y
N
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Discover Scuba Diving Knowledge and Safety Review
These practices have been compiled for your review and acknowledgment and are intended to increase your comfort and safety in diving. I understand that upon completing the Discover Scuba Diving programme, I will not be qualified to dive independently without a certified professional guiding me. To equalize my ears and sinus air spaces, I will need to blow gently against pinched nostrils every few feet/one metre while descending. lf I have discomfort in my ears or sinuses during descent, I should stop my descent and alert my instructor. Underwater, I should breathe slowly, deeply, continuously and never hold my breath. I should respect underwater life and not touch, tease or harass an underwater organism since it may harm me and/or I may harm it. I can seek further training from any PADI Dive Centre, Resort and instructor to become certified to dive without a professional guide
Statement of Risks and Liability I (participant name),
I (participant name),
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hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. I affirm I have read and understand the Safe Diving Practices and have had any questions answered to my satisfaction. I understand the importance and purposes of these established practices. I recognise they are for my safety and well being, and that failure to adhere to them can place me in jeopardy when diving. I understand that diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. I further understand that this programme may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with this programme in spite of the absence of a recompression chamber in proximity to the dive site. The information I have provided about my medical history on the Medical Questionnaire is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions. I further understand that skin diving and scuba diving are physically strenuous activities and that l will be exerting myself during this programme. I further state that I am of lawful age and legally competent to sign this Statement of Risks and Liability, or that I have acquired the written consent of my parent or guardian. Neither the teaching instructor(s), Kostas Sgourakis, the facility through which this training is offered, Mykonos Diving Center / Dive Adventures, PADI lnternational Ltd., or PADl Americas, lnc., accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any manner or condition under my control which amounts to my own contributory negligence. ln the absence of any negligence or other breach of duty by the teaching instructor(s) , Kostas Sgourakis, the facility through which this training is offered, Mykonos Diving Center / Dive Adventures , PADI lnternational Ltd., or PADl Americas, lnc., my participation in this diving course is entirely at my own risk.
I have fully informed myself of the contents of this Statement of Risks and Liability by reading it before signing it
Participant Name
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Participant Signature
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Date
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Parent/Guardian Signature (where applicable)
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EMERGENCY CONTACT INFORMATION In case of emergency, contact: (Please supply as much information as you can)
Name
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Relationship
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Residence Phone
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Work Phone
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E-mail
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