^PADI Student Record File Home Phone

Mobile Phone

UNDERSEA^

HYPERBARIC

MEDJCALSOaEIY

Please read carefully before signing. mSSSSSSSSSmSSSSSSmThis is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is underof you during the scuba training program. Your signature on this statement is required for you to participate in the scuba the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions ortraining program. In addition, if your medical condition changes at any time during your scuba programs it is important you are taking medications on a regular basis, you should consult your doctor and the instructor before participating inthat you inform your instructor immediately. this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the importantRead thisstatementpriortosigningit.YoumustcompletethisMedical Statement, which includes themedical questionnaire regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result insection, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent serious injury. You must be thoroughly instructed in its use under direct supen/ision of a qualified instructor to use it safely,or guardian. Diving is an exciting and demanding aaivity. When performed correctly, applying correct techniques, it is If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review themrelatively safe. When established safety procedures are not followed, however, there are increased risks. with your instructor before signing.To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certainconditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and

Divers Medical QuestionnaireTo the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your'doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from divingA positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.Please answer the following questions on your past or 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 itscuba diving. Your instructor wilt supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician.

Could you be pregnant, or are you attempting to become pregnant?

Are you presently taking prescription medications? (with the exception ofbirth control or anti-malarial)

Are you over 45 years of age and can answer YES to one or more of thefollowing?• currently smoke a pipe, cigars or cigarettes• are currently receiving medical care• have a high cholesterol level• high blood pressure• have a family history of heart attack or stroke• diabetes mellitus. even if controlled by diet alone

Have you ever had or do you currently have...

Asthma, or wheezing with breathing, or wheezing with exercise?

Frequent or severe attacks of hayfever or allergy?

Frequent colds, sinusitis or bronchitis?

Any form of lung disease?

Pneumothorax (collapsed lung)?

Qther chest disease or chest surgery?

Behavioral health, mental or psychological problems (Panic attack, fearof closed or openspaces)?

Epilepsy, seizures, convulsions or take medications to prevent them?

Recurring complicated migraine headaches or take medications toprevent them?

Blackouts or fainting (full/partial loss of consciousness)?

Frequent or severe suffering from motion sickness (seasick,carsick, etc.)?

Dysentery or dehydration requiring medical Intervention?

Any dive accidents or decompression sickness?

Inability to perform moderate exercise (example; walk 1.6 km/one milewithin 12 mins.)?

Head injury with loss of consciousness in the past five years?

Recurrent back problems?

Back or spinal surgery?

The information I have provided about my medical history is accurate to the best of my knowledge. I affirm it is my responsibility to inform my instructor of any and all changesI agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition, or any changes thereto.

Diabetes?

Back, arm or leg problems following surgery, injury or fracture?

High blood pressure or take medicine to control blood pressure?

Heart disease?

Heart attack?

Angina, heart surgery or blood vessel surgery?

Sinus surgery?

Ear disease or surgery, hearing loss or problems with balance?

Recurrent ear problems?

Bleeding or other blood disorders?

Hernia?

Ulcers or ulcer surgery ?

A colostomy or lleostomy?

Recreational drug use or treatment for, or alcoholism in the pastfive years?

to my medical history at any time during my participation in scuba programs.

Non-Agency Disclosurs Anci AcknQwi6dgrnGnt AgrQement in European Union and European Free Trade Association countries use alternative form.

I understand and agree that PADI Members ("Members"), including responsible for, nor does It have the right to control, the operation of the Members' business activities and the day-to day conducand/orany individual PAOIInstructors and Divemastersassociatedwith the program In which I am participating, are licensed to use of PADI programs and supervision of divers by the Members ortheir associated staff.) further understand and agree on behalf o

parent, subsidiary and affiliated corporations ("PADI"). I further understand that Member business activities are independent, and PADI liable for the actions, inactions ornegligenceof.are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver training programs, it is not instructors and divemasters associated with the activity.

Standard Safe Diving Practices Statement of Understanding

Liability Release and Assumption of Risk Agreement In European Union and European Free Trade Association countries use alternative form.

Please read carefully before signing.

This is a statement in which you are informed of the established safe diving practices for skin and scuba diving. These 5, Adhere to the buddy system throughout every dive. Plan dives - including communications, procedures for reuniting' ' ' in case of separation and emergency procedures - with my buddy.

6. Be proficient in dive planning (dive computer or dive table use). (Vake all dives no decompression dives and allow amargin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training

practices have been compiled for your review and acknowledgement and are intended to increase your comfort and safetyin diving. Your signature on this statement is required as proof that you are aware of these safe diving practices. Readand discuss the statement prior to signing it. If you are a minor, this form must also be signed by a parent or guardian.1, understand that as a diver I should: and experience! Ascend at a rate of not more than 18 metres/60 feet per minute. Be a SAFE diver - Slowly Ascend

, u r. r , u . j j From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer.1. Maintain good mental and physical fitness for diving. Avoid being under the influence ot alcohol or dangerous drugswhen diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing 7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy controlthem in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and ' -- - - • ••- z i i n u-refresh myself on important information.

2. Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If divingconditions are worse than those in which I am experienced, postpone diving or select an alternate site with betterconditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave ortechnical diving unless specifically trained to do so.

3. Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correa fit and functionprior to each dive. Have a buoyancy control device, low-pressure buoyancy control inflation system, submersible pres-

device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weightsclear for easy removal, and establish buoyancy when in distress while diving. Carry at least one surface signalingdevice (such as signal tube, whistle, mirror).

8. Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessivehyperventilation when breath-hold diving. Avoid overexertion while in and undenwater and dive within my limitations.

9- Use a boat, float or other surface support station, whenever feasible.

10. Know and obey local dive laws and reguialions, including fish and game and dive flag laws.

sure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—whichever I understand the importance and purposes of these established practices. I recognize they are for my ownyou are trained to use) when scuba diving. Deny use of my equipment to uncertified divers. safety and weli-being, and that failure to adhere to them can place me in jeopardy when diving.

4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recognize that additional training is recommended for participation in specialty diving activities, in other geographicareas and after periods of inactivity that exceed six months.

Please read carefully and fill in all blanks before signing.

I_ , hereby affirm that I am aware that skin and scuba diving have I also understand that skm diving and scuba diving are physically strenuous activities and that 1 will be exerting myselfinherent risks which may result in serious injury or death.

I understand that diving with compressed air involves certain inherent risks; including but not limited to decompressionsickness, embolism or other hyperbaric/air expansion injury that require treatment in a recompression chamber. I further I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired theunderstand that the open water diving trips which are necessary for training and for certification may be conducted at written consent of my parent or guardian. I understand the terms herein are contractual and not a mere recital, anda site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legalwith such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site. rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid, that provision shall

be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceableI understand and agree that neither my instructor(s), . the facility had never been contained herein.

1 understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs,through which I receive my instruction, nor PAD! Americas, assigns or beneficiaries may have to sue the Released Parties resulting from my death. I further represent I have theInc., nor its affiliate and subsidiary corporations, nor any of their respective employees, officers, agents, contractors or authority to do so and that my heirs, assigns, or beneficiaries will be estopped from claiming otherwise because of myassigns (hereinafter referred to as "Released Parties") may be held liable or responsible in any way for any injury, death representations to the Released Partiesor other damages to me, my family, estate, heirs or assigns that may occur as a result of my participation in this divingprogram or as a result of the negligence of any party, including the Released Parties, whether passive or active.

In consideration of being allowed to participate in this course (and optional Adventure Dive), hereinafter referred toas "program," 1 hereby personally assume ail risks of this program, whether foreseen or unforeseen, that may befall anD RELEASE MY INSTRUCTORS,me white I am a participant in this program including, but not limited to, the academics, confined water and/or openwater activities. I RECEIVE MY INSTRUCTION, _

I further release, exempt and hold harmless said program and Released Parties from any claim or lawsuit by me, myfamily, estate, heirs or assigns, arising out of my enrollment and participation in this program including both claimsarising during the program or after I receive my certification.

., nor PADI Americas,

during this program, and that if I am injured as a result of heart attack, panic, hyperventilation, drowning or any othercause, that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same.

BY THIS INSTRUMENT AGREE TO EXEMPT

THE FACILITY THROUGH WHICH

, AND PADI AMERICAS, INC.,AND ALL RELATED ENTITIES AS DEFINED ABOVE, FROM ALL UABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, INCLUDING, BUT NOT LIMITED TO, THENEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE.

I HAVE FULLY INFORMED MYSELF OFTHE CONTENTS OF THIS MEDICAL STATEMENT. NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT, STANDARD SAFE DIVING PRACTICES STATEMENT OF UNDERSTANDINGAND UABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT BY READING BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS.

Signature of Parent or Guardian (where applicable)

Participant's Signature Date (Day / Month / Year)

Date (Day / Month / Year)

PADI Open Water Diver Course Record and Referral Form

Student Name

Birth Date / /Day Month Year

Mailing address

Sex M F

A. CONFINED WATER DIVESDate Completed Instructor"Day/Montn/Year Initials

B. KNOWLEDGE DEVELOPMENT Course option: RDP Table DeRDPML Computer onlyDate CompletedDate Comp

Day/MonthCompleted Passed Viewed Open Instructor**

KR Quiz/Exam Water Vitieo Initials

State/Province Country Zip/Postal Code

Phone Home

Business

All PADI Instructors who initial this document must complete anidentification section below.Note: Attach additional sheet /or other PADI Instructor information if necessary

PADI lnstructor__

Signature

PAD! No.

Date / /Day Month Year

Phone Home (

Dive Center/Resort No.

PADI Instructor

Signature

PADI No. Dive Center/Resort No.

Date / /Day Month Year

Phone Home ( ).

When referring a PADI Scuba Diver/Open Water Diver student:a. fill in the diver and PADI Instructor information and note appropriate areas of

training completed.b. Attach a copy of the diver's PADI Medical Statement to this form.c. Advise the diver of the need for a photo for certification card processing.d. Encourage the diver to complete training as soon as possible and explain that this

form is only valid for one year from the last training section completion date.

'DSD vAth all CW Dive I skills = Open Water Diver CW Dive I

Waterskills Assessment

200 metre/yard Swim OR 300 metre^ard Mask/Snorkel/Fin Swim

/ / #

10 Minute Sun/ival Float*

Confined Water Dive Flexible SkillsEquipment Preparation and Care*

/ / #.

Disconnect Low Pressure Inflator Hose*

Loose Cylinder Band

Weight System Removal and Replacement (surface)*

Emergency Weight Drop (or in OW)*

Skin Diving Skills

Dry Suit Orientation

(Note: If all Confined Water Dives, Confined Water Dive Flexible Skills andWaterskills Assessment have been completed by one instructor, on/y onesignafure required.)

All Confined Water Dives, Confined Water Dive Flexible Skillsand Waterskills Assessment have been completed.

Instructor Signature.

Date / /Day Month Year

**! certify that this student has satisfactorily completedthis skill/section/dive as outlined in the PAD! IrtstrvctorManual. I am a PADI instructor renewed in Teaching statusfor the current year.

OR elearningQuick Review / / : #(Note: If all above Knowledge Development sessions have been completed by one instnKtor, only one signature required)

All Knowledge Development sessions listed above have been completed, Quizzes/Exams passed.

Instructor Signature # Date / /Month Year

C. OPEN WATER DIVESDate Completed

Day/Montn/YearInstructor"

InitialsDate Completed Instructor"

Day/Month/Year Initials

Open Water Dive Flexible Skills - These skills may be completed during any OpenWater Training Dive.

Completed on Instructor Initials** PADti

1. Cramp Removal* Dive# #

2. Snorkel/Regulator Exchange* Dive# #

3. inflatable SignalTube/DSMB Deployment* Dive# #4. Emergency Weight Drop (or in CW)* Dive # #

5. Surface Swim with Compass Dive# #6. Tired Diver Tow Dive# #

7. Remove/Replace Scuba (surface) Dive# #8. Remove/Replace Weights (surface) Dive # #

9. CESA(Dive2.3or4) Dive# #

10.UW Compass Navigation (Dive 2,3 or 4) Dive# #(Note: If ail above Dive Flexible Skills have been completed by one instructor, only one signature is required)

All Open Water Dive Flexible Skills listed above have been completed.

Instructor Signature # Date / /Day Month Year

Student Statement: 1 understand the training requirements for this course and have successfullycompleted ail certification requirements. I am adequately prepared to dive in areas and underconditions similar to those in which 1 was trained. I realize that additional training is recommended for participation in specialty diving activities, in other geographical areas, and after periodsof inactivity that exceed six months. I agree to abide by PADi's Standard Safe Diving Practices.

Student Signature Date _ / /Month Year

All requirements for certification as a PADI Scuba Diver have been met (completion of Knowledge Development sessions 1,2,3 Confined Water Dives 1, 2,3 Open Water Dives 1,2 and all diveflexible skills marked with an asterisk *).

Instruaor Signature # Date / /Month Year

All requirements for certification as a PADI Open Water Diver have been met.

Instructor Signature # Date / /Month Year

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