VD自潛課報名表 Reservation

中文全名

姓名英文拼音(同護照)

生日

報名課程 Course

開課日(泳池第一天)

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是否曾經或目前有以下醫療史，而且可能會影響潛水安全? Do you have (before or presently) any of the following medical history that could possibly affect your safety in the water or increase the risk of diving?

腦神經方面，尤其是癲癇或大腦血管動脈瘤、嚴重偏頭痛、復發性昏厥或暈眩、腦部手術、中風Neurological Conditions: Especially any history of seizure disorder, stroke, brain surgery, repeated black outs or fainting fits, severe migraine headaches, or aneurysm of the brain‟s blood vessels

心血管方面，例如高血壓疾病、心臟手術、心臟病、心律不整 Cardiovascular Conditions: Especially heart attack, heart surgery, irregular heart beat, uncontrolled elevated blood pressure

肺部方面，例如肺部萎縮、氣胸、肺囊腫、氣囊、肺組織受損或任何會影響呼吸的疾病Pulmonary Conditions: Especially a history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, severe damage to lung tissue, emphysema, or any lung problem which interferes with your ability to breathe

耳朵方面，例如耳膜受損、耳膜穿孔、永久耳管、聽力受損、重大耳部手術等Ear Conditions: Permanent holes of the eardrums, history of ruptured eardrum, permanent tubes in eardrums, severely impaired hearing or hearing loss in one or both ears, or major ear surgery

鼻竇方面，例如持續性鼻竇炎、鼻息肉、重大鼻竇手術、囊腫、腫瘤等Sinus Conditions: Tumor, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, or persistent sinus infection

曾經或現在有氣喘史，任何因運動引起，或需藥物控制，或需使用呼吸輔助器的氣喘史Asthma: History of asthma or asthma attacks. Any history of wheezing caused by exercise, anxiety, cold, fatigue, etc. Any condition requiring medication and/or use of an inhaler for control of wheezing

糖尿病Diabetes

懷孕Pregnancy

重大潛水意外，例如減壓症或內耳氣壓傷等Freediving/ Scuba Diving Conditions

正在服用藥物，可能影響水中安全或判斷Medication: Any medication taken on a regular basis either over-the-counter or prescribed by a physician

其他未提及但可能影響水中狀態之身體、心理、情緒方面問題General Medical Problems that might physically or emotionally effect your safety in an underwater environment or affect your judgment under times of physical or emotional stress

近兩周內曾確診新冠病毒Tested positive for Covid-19 in the past 2 weeks

無，一切OK. Non of the above.

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如您臨時無法出席，請提前至少一個月與教練更改時間，或轉讓給親友。大家的時間都很寶貴，請互相尊重。 If you can't make it last minute, please let us know at least a month in advance to reschedule or pass your spot to someone else. Let's all respect each other's time.

如遇颱風或是海況不佳的情形，課程會改期。如必須取消，我們會扣除已支出的費用，退回剩下的金額。

In case of a typhoon or unfavorable sea conditions, the course will be rescheduled. If cancellation becomes necessary, we will deduct the expenses incurred and refund the remaining amount.

所有學員皆須會游泳，我們不接受因不會游泳或心理狀況不佳等情形取消/延期課程。

Please note that all participants should have swimming proficiency. We may not be able to accommodate course cancellations or postponements due to difficulties in swimming or personal psychological factors.

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我同意以上規則 I agree with the terms and conditions mentioned above