Discover Scuba® Diving Participant Statement
Emergency Contact: (Name and Phone and Relationship)
Room Number/ Villa Number:
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Statement of Understanding – Triton Adventures
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By participating in snorkelling, certified diving, Discover Diving Programs or SUP trips with Triton Adventures, I understand that I am responsible for any loss or damage to the equipment provided. I agree to use all gear with care and acknowledge that, in the event of loss or damage, I will be charged the full replacement cost at the price of a new item.
Statement of Understanding – Triton Adventures
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.
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Non-Agency Disclosure and Acknowledgment Agreement
I understand and agree that PADI Members (“Members”), including THE FACILITY THROUGH WHICH THIS ACTIVITY IS CONDUCTED, INCLUDING TRITON LEARNING CENTER LTD, ITS DIRECTORS, EMPLOYEES, AND AFFILIATED PARTIES, and Independent Instructors renting equipment and performing programs from the Center.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 TRITON LEARNING CENTER LTD, ITS DIRECTORS, EMPLOYEES, AND AFFILIATED PARTIES and/or the instructors and divemasters associated with the activity.
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.
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, TRITON LEARNING CENTER LTD, ITS DIRECTORS, EMPLOYEES, AND AFFILIATED PARTIES, 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.
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. 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.
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Diver Medical | Participant Questionnaire
1 | Do you currently have an ear infection?
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1 | Do you currently have an ear infection?
2 | Do you have a history of ear disease, hearing loss or problems with balance?
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2 | Do you have a history of ear disease, hearing loss or problems with balance?
3 | Do you have a history of ear or sinus surgery?
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3 | Do you have a history of ear or sinus surgery?
4 | Are you currently suffering from a cold, congestion, sinusitis or bronchitis?
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4 | Are you currently suffering from a cold, congestion, sinusitis or bronchitis?
5 | Do you have a history of respiratory problems, severe attacks of hayfever or allergies, or lung
disease?
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5 | Do you have a history of respiratory problems, severe attacks of hayfever or allergies, or lung
disease?
6 | Have you had a collapsed lung (pneumothorax) or history of chest surgery?
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6 | Have you had a collapsed lung (pneumothorax) or history of chest surgery?
7 | Do you have active asthma or history of emphysema or tuberculosis?
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7 | Do you have active asthma or history of emphysema or tuberculosis?
8 | Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities?
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8 | Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities?
9 | Do you have behavioral health, mental or psychological problems or a nervous system disorder?
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9 | Do you have behavioral health, mental or psychological problems or a nervous system disorder?
10 | Are you or could you be pregnant?
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10 | Are you or could you be pregnant?
11 | Do you have a history of colostomy?
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11 | Do you have a history of colostomy?
12 | Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?
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12 | Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?
13 | Do you have a history of high blood pressure, angina, or take medication to control blood pressure?
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13 | Do you have a history of high blood pressure, angina, or take medication to control blood pressure?
14 | Are you over 45 and have a family history of heart attack or stroke?
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14 | Are you over 45 and have a family history of heart attack or stroke?
15 | Do you have a history of bleeding or other blood disorders?
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15 | Do you have a history of bleeding or other blood disorders?
16 | Do you have a history of diabetes?
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16 | Do you have a history of diabetes?
17 | Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?
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17 | Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?
18 | Do you have a history of back, arm or leg problems following an injury, fracture or surgery?
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18 | Do you have a history of back, arm or leg problems following an injury, fracture or surgery?
19 | Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?
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19 | Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?
If you answered NO to all 16 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 any of these questions, then you must additionally complete the Diver Medical Participation Questionnaire. The Diver Medical Participation Questionnaire is a more thorough medical screening form used to determine if you need to be evaluated by a physician prior to any in-water diving activities. PLEASE UPLOAD IT HERE:
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Participant's Signature or parent or Guardian (if applicable) and Agreement (By checking this box is agreed as a digital Signature and is usable in a court of law)
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