NEMO DIVER TRAINING LTD  - Try Dive Scuba Experience & Snorkelling Medical Statement
Certificate of Understanding and Express Assumption of risk
Please read carefully before signing

I, (participant name)_______________________________________  Understand that diving with compressed air involves certain inherent risks; de-compressions sickness, embolism, or other hyperbaric injuries can occur that re-quire treatment in a recompression chamber.

I understand and agree that neither my Instructors, the facility through which I receive my Instruction (Nemo Diver training Ltd), PADI International Ltd and its subsidiary or affiliate 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 or my family, heirs, or assigns that may occur as a result of my participation in this diving programme or as a result of any matter or condition under my control.

In consideration of being allowed to enrol in this program, I hereby personally assume all risks in connection with said program, for any harm, injury or damage that may befall me while I am enrolled as a participant in this program, including all risks connected therewith, whether foreseen or unforeseen.

I also understand that scuba diving is a physically strenuous activity and that I will be exerting myself during this diving 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 above listed individuals or companies responsible for the same.

I understand that the PADI Experience Programs are designed to provide me with an introduction to scuba diving.  The programs are not intended to train me as a competent diver.  I further understand and agree that I must be thoroughly instructed in the use of scuba in a certification course under the direct supervision of a qualified instructor to become a certified, competent diver.

I further state that I am of lawful age and legally competent to sign this certificate of understanding, or that has 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 document of my own free act.

It is the intention of (Participant Name)____________________________ by this instrument to exempt and release my Instructors, the facility through which I received my instruction (Nemo Diver Training Ltd) and PADI International Ltd.  And all related entities as defined above, from all liability or responsibility whatsoever for personal injury, property damage or wrongful death, which results from my own conduct or any matter or condition under my control.

I acknowledge that I have also read and understand the PADI experience programmes medical statement before signing it on behalf of myself and my heirs.

I have fully informed myself of the contents of this certificate of understanding and express assumption of risk by reading it before I Signed it on behalf of my heirs and myself.


________________________________________       Date______________
Signature of Participant                                                       Day/Month/Year


_______________________________________        Date_______________
Signature of Parent or Guardian (where applicable)                 Day/Month/Year

PADI EPERIENCE PROGRAMS MEDICAL STATEMENT
Please read carefully before signing (Confidential Information)

This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the PADI Experience Programs.  Your signature on this statement is required in order to participant in the PADI Experience Programs offered by Nemo Diver Training Ltd located in the county of Nottinghamshire.

Read this statement prior to signing it.  You must complete this PADI Experience Programs Medical Statement/Questionnaire, which includes the medical history section, to enrol in the PADI Experience Programs.  If you are a minor, you must have this PADI Experience Programs Medical Statement/Questionnaire signed by a parent or guardian.

Scuba diving is an exciting and demanding activity. When preformed correctly, applying correct techniques, it is safe.  When established safety procedures are not followed, however, there are dangers.  To scuba dive safely, you must not be extremely overweight or out of condition.  Diving can be strenuous under certain condition.  You’re 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.  If taking medication, consult your doctor before participating in this program.  

You will also need to learn from the instructor the important safety rules regarding breathing and equalization while scuba diving.  Improper 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.  




MEDICAL HISTORY/QUESTIONNAIRE
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 advice of a physician.

Please answer the following questions on your passed and 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 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?

_____ Do you have a history of ear disease, hearing lose or problems with balance?                                   
_____   Do you have a history of ear or sinus surgery?

_____   Are you currently suffering from a cold, congestion, sinusitis or bronchitis?

_____  Do you have a history of respiratory problems, severe attack of hay fever or allergies, or             lung disease?

_____   Have you had a collapsed lung (pneumothorax) or history of chest surgery?

_____   Do you have active asthma or history of emphysema or tuberculosis?

_____  Are you currently taking medication that carries a warning about any impairment of your             physical or mental abilities?

_____   Do you have behavioural health problems or a nervous system disorder?

_____   Are you or could you pregnant?

_____   Do you have a history of colostomy?

_____  Do you have a history of heart disease or heart attack, heart surgery or blood vessel             surgery?

_____  Do you have a history of high blood pressure, angina, or take medication to control blood             pressure?

_____   Are you over 45 and have a family history of heart attack or stroke?

_____   Do you have a history of bleeding or other blood disorder?

_____   Do you have a history of diabetes?

_____   Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy
           or take medication to prevent them?

_____   Do you have a history of back, arm or leg problems following an injury, fracture or surgery?

_____   Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or             agoraphobia)?




The information I have provided about my medical history is accurate to the best of my knowledge.


Name ______________________________________________________


Date of Birth_____________Shoe size_____________chest size_______


Address______________________________________________________

____________________________Tel No.___________________________


__________________________________      Date___________________
Participant Signature                                          Day/Month/Year


__________________________________      Date___________________
Parent/Guardian Signature (where applicable)         Day/Month/Year