Name: Discover Scuba Diving
Start: 2023-08-26 13:00:00
End: 2023-08-26 16:00:00
Location: Indian Valley Scuba

A program designed to introduce the scuba experience to non-certified participants meeting minimum age and health requirements.

Discover Scuba

Discover Scuba Diving

A program designed to introduce the scuba experience to non-certified participants meeting minimum age and health requirements. This may be conducted in a pool or confined water, and if certain conditions are met, may be expanded to include an actual open water dive.

2023 - 8 Discover Scuba Diving Registration Form - 8-26-23

There are currently 10 available spots in this class.

Program Completion Date: 8/26/2023

Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY

Please note that the minimum age for this event is 8 years old!
Phone*
Email*
Gender*
- Male
- Female
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 on the back panel. 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.
Non-Agency Disclosure and Acknowledgment Agreement and Liability Release and Assumption of Risk*
I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT AND NON-AGENCY DISCLOSURE ACKNOWLEDGMENT AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS AND AFFIRM THE MEDICAL QUESTIONNAIRE IS ACCURATE.
Non-Agency Disclosure and Acknowledgment Agreement

I understand and agree that PADI Members (“Members”), including Indian Valley Scuba 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 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.

I further understand and agree on behalf of myself, my heirs and my estate that in the event of an injury or death during this activity, neither I nor my estate shall seek to hold PADI liable for the actions, inactions or negligence of Indian Valley Scuba and/or the instructors and divemasters associated with the activity.

Liability Release and Assumption of Risk Agreement

I (participant name), ____________________________, hereby affirm that I aware that skin and scuba diving have inherent risks which may result in serious injury or death.
I understand that diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injuries can occur that require treatment in a recompression chamber.

I further understand that this program 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 program in spite of the absence of a recompression chamber or medical facility 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 understand and agree that neither the dive professionals conducting this program, nor the facility through which this program is offered, Indian Valley Scuba, nor PADI Americas, Inc., nor its affiliate or subsidiary corporations, 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 me, my family, estate, heirs or assigns that may occur as a result of my participation in this program or as a result of the negligence of the Released Parties, whether passive or active.

In consideration of being allowed to participate in this program, I hereby personally assume all risks for any harm, injury or damage, whether foreseen or unforeseen, that may befall me while participating in this program, including but not limited to the knowledge development, confined water and/or open water activities.

I further release and hold harmless the Discover Scuba Diving program and the Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my participation in this program.

I further understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this program and that if I am injured as a result of heart attack, panic, hyperventilation, etc., that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same.

I further state that I am of lawful age and legally competent to sign this Liability Release and Assumption of Risk Agreement, or that I have acquired the written consent of my parent or guardian.

I understand that the terms herein are contractual and not a mere recital and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal 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 unenforceable provision had never been contained herein.

I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns or beneficiaries may have to sue the Released Parties resulting from my death. I further represent that I have the authority to do so and that my heirs, assigns and beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties.

I (participant name), _______________________________, BY THIS INSTRUMENT DO EXEMPT AND RELEASE THE DIVE PROFESSIONALS CONDUCTING THIS PROGRAM, THE FACILITY THROUGH WHICH THE PROGRAM IS CONDUCTED, AND PADI AMERICAS, INC., AND ALL RELATED ENTITIES AND RELEASED PARTIES 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.
Diver Medical Participant Questionnaire
Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.
Directions
Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course. Note to women: If you are pregnant, or attempting to become pregnant, do not dive.
1.) I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.*
- Yes
- No
I have/have had:
Chest surgery, heart sugery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung)*
- Yes*
- No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.*
- Yes*
- No
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.*
- Yes*
- No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.*
- Yes*
- No
A diagnosis of COVID-19.*
- Yes*
- No
2.) I am over 45 years of age.*
- Yes
- No
I am over 45 years of age AND:
I currently smoke or inhale nicotine by other means.*
- Yes*
- No
I have a high cholesterol level.*
- Yes*
- No
I have high blood pressure.*
- Yes*
- No
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).*
- Yes*
- No
3.) I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.*
- Yes*
- No
4.) I have had problems with my eyes, ears, or nasal passages/sinuses.*
- Yes
- No
I have/have had:
Sinus surgery within the last 6 months.*
- Yes*
- No
Ear disease or ear surgery, hearing loss, or problems with balance.*
- Yes*
- No
Recurrent sinusitis within the past 12 months.*
- Yes*
- No
Eye surgery within the past 3 months.*
- Yes*
- No
5.) I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.*
- Yes*
- No
6.) I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.*
- Yes
- No
I have/have had:
Head injury with loss of consciousness within the past 5 years.*
- Yes*
- No
Persistent neurologic injury or disease.*
- Yes*
- No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.*
- Yes*
- No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.*
- Yes*
- No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.*
- Yes*
- No
7.) I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disabiltiy.*
- Yes
- No
I have/have had:
Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.*
- Yes*
- No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.*
- Yes*
- No
Been diagnosed with amental health condition or a learning/development disorder that requires ongoing care.*
- Yes*
- No
An addiction to drugs or alcohol requiring treatment with the last 5 years.*
- Yes*
- No
8.) I have had back problems, hernia, ulcers, or diabetes.*
- Yes
- No
I have/have had:
Recurrent back problems in the last 6 months that limit my everyday activity.*
- Yes*
- No
Back or spinal surgery within the last 12 months.*
- Yes*
- No
Diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.*
- Yes*
- No
An uncorrected hernia that limits my physical abilities.*
- Yes*
- No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.*
- Yes*
- No
9.) I have had stomach or intestine-problems, including recent diarrhea.*
- Yes
- No
I have had:
Ostomy surgery and do not have medical clearance to swim or engage in physical activity.*
- Yes*
- No
Dehydration requiring medical intervention within the last 7 days.*
- Yes*
- No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.*
- Yes*
- No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD)*
- Yes*
- No
Active or uncontrolled ulcerative colitis or Crohn's disease.*
- Yes*
- No
Bariatric surgery within the last 12 months.*
- Yes*
- No
10.) I am taking prescription medications (with exception of birth control or anti-malarial drugs other than mefloquine/Lariam).*
- Yes*
- No
I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT AND NON-AGENCY DISCLOSURE ACKNOWLEDGMENT AGREEMENT BY READING BOTH BEFORE SIGNING BELOW ON BEHALF OF MYSELF AND MY HEIRS AND AFFIRM THE MEDICAL QUESTIONNAIRE IS ACCURATE.
If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.
Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.
* If you answered YES to question 3, 5 or 10 above OR to any of the follow up questions, please read and agree to the statement above by signing and dating AND contact Indian Valley Scuba. Participation in a diving course requires your physician's approval.
Signature*
Parent/Guardian Signature (where applicable)
Coupon/Code/Gift Certificate

Do you have a coupon code or gift certificate? If yes, please enter it here.
Model Release
I agree to the Model Release
For valuable consideration, including possible publication of my image, receipt of which I acknowledge, I hereby grant the worldwide, perpetual right and permission to photograph/videotape, use, copyright, publish and republish, broadcast and rebroadcast, and/or distribute and redistribute photos and/or videos, in whole or in part, of me, to INDIAN VALLEY SCUBA, for use in articles, advertising, or for any other purposes in printed or electronic or any other media including but not limited to magazines, books, newsletters, web sites, CD-ROMs, DVDs, tapes and other forms of still and/or motion media, now existing or yet to be created. I further grant INDIAN VALLEY SCUBA the right to transfer and/or assign this right and permission, permanently or temporarily, to any person, agent, entity or company in connection with said purposes. I acknowledge that the photograph(s)/video(s) may be altered, enhanced or edited through photographic or computer methods.I hereby release and discharge INDIAN VALLEY SCUBA and their assigns, agents and/or all persons acting under their permission and authority or those for whom they may be acting, from and against any liability as a result of this release, including but not limited to liability caused by any distortion, blurring, alteration or optical illusion that may occur in the taking of the photographs/video or in processing, reproduction or editing of the u001ffinished photograph(s)/video(s) and assume these risks myself.

I hereby release and discharge INDIAN VALLEY SCUBA and their assigns, and all persons acting under their permission and authority or those for whom they may be acting, from and against any liability that results from the use of the photograph(s)/video(s), and assume any such risks myself. I waive any right to inspect said photograph(s)/video(s) in its/their original, enhanced, or edited form prior to publication, duplication, broadcast or other use in any form of media. I understand that no payment or consideration other than as stated in this agreement will be paid to me now or in the future.
I agree that copyright ownership of any photos, video, or other media resulting from this agreement shall be owned by INDIAN VALLEY SCUBA or its au001eliate(s) as INDIAN VALLEY SCUBA shall decide.

I hereby warrant that I am of full age and competent to contract in my own name in so far as the contents of this release are concerned; or, if the Model/actor is under age 18, that I am the parent or legal guardian of the Model/actor and I have the legal right to sign this agreement on the Model/actor's behalf. I have read the above and I fully understand its contents.
Name
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Discover Scuba

Discover Scuba Diving

2023 - 8 Discover Scuba Diving Registration Form - 8-26-23

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