Blue Bubble Divers, Cozumel, Mexico - Diving Form for Printing.

BLUE BUBBLE DIVERS, Cozumel, Mexico

DIVING APPLICATION

*Required Fields Help? PLEASE READ THE REFUND POLICY AT THE BOTTOM OF THE PAGE

*DATE: _____/_____/________ *NAME: _______________________________________________________ E-MAIL: ____________________________________________

*HOTEL: _________________________ ROOM NO.: __________ COUNTRY OF ORIGIN: ____________________ *DATE OF BIRTH : ____/_____/________

*EMERGENCY PHONE: ( _____ )_______________________ *CERTIFICATION LEVEL: ________________ *AGENCY: _____________ *CERT. NO.: _______________

*EXPERIENCE

LAST DIVE(Aprox.):____/____/______ APROX. No. OF DIVES: _________ MAX. DEPTH: _______ ft. OCEAN DIVES?: yes no DRIFT DIVING?: yes no WALL DIVE?: yes no

NIGHT DIVE?: yes no ARE YOU CONFIDENT TO DIVE?: yes no DO YOU NEED A REFRESHER COURSE?: yes no

*STATEMENT OF UNDERSTANDING AND WAIVER

I AM AWARE OF THE INHERENT HAZARDS OF SCUBA DIVING AND AGREE AND DECLARE THAT:

- I AM IN GOOD PHYSICAL AND MENTAL CONDITION FOR DIVING.
- I CAN NOT DIVE UNDER THE INFLUENCE OF ALCOHOL OR DRUGS WHEN DIVING.
- I WILL ENGAGE ONLY IN DIVING ACTIVITIES CONSISTENT WITH MY TRAINING AND EXPERIENCE.
- I WILL LISTEN CAREFULLY TO THE DIVE BRIEFING AND FOLLOW ALL THE INSTRUCTIONS BY THE DIVEMASTER/INSTRUCTOR WHO LEADS THE DIVE.
- I WILL NEVER EXCEED DEPTH OR TIME LIMITATIONS PLANNED BY THE DIVEMASTER/INSTRUCTOR.
- I WILL ADHERE TO GROUP DIVE SYSTEM THROUGHOUT EVERY DIVE.
- I WILL MAINTAIN PROPER BUOYANCY CONTROL WHEN DIVING AND DO MY BEST TO AVOID CAUSING DAMAGE TO THE REEF.
- I WILL NOT TOUCH OR COLLECT ANYTHING AND AVOID BOTHERING MARINE CREATURES, AND UNDERSTAND THAT I WILL BE DIVING IN COZUMEL’S NATIONAL UNDERWATER PARK AND FOLLOW ALL OF IT’S LAWS.

*I, ___________________________ HAVE READ AND DO FULLY UNDERSTAND ALL THE ABOVE STATED INFORMATION AND AGREE TO ALL OF THE CONTENT IN THIS DOCUMENT. IT IS MY INTENTION TO EXCEMPT AND RELEASE BLUE BUBBLE DIVERS, KINGAB AND ITS AGENTS FROM ALL LIABILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY LOSS OR DAMAGE, WRONGFUL DEATH OR NEGLIGENCE THROUGH AN ACCIDENT. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE BY READING IT BEFORE I SIGNED IT AND HAVE HAD ANY QUESTIONS ANSWERED TO MY SATISFACTION.

_____________________________
*CLIENT SIGNATURE

BLUE BUBBLE DIVERS IS AFFILIATED TO HYPERBARIC SERVICES THROUGH SUBAQUATIC SAFETY SERVICES BUCEO MEDICO MEXICANO

EQUIPMENT NEEDED

Buoyancy Control Device (BCD)?: yes Regulator?: yes Fins?: yes Mask?: yes Wetsuit?: yes Dive Light?: yes Dive Computer? yes

Other?:_____________________________________________________

REFUND POLICY: CANCELLATIONS MUST BE MADE BEFORE 9:00 P.M. ON THE PREVIOUS NIGHT OF SERVICE TO RECEIVE A FULL REFUND. 50% WILL BE REFUNDED FOR CANCELLATIONS MADE AFTER 9:00 P.M. ON THE PREVIOUS NIGHT OF SERVICE. NO REFUND WILL BE MADE FOR NO SHOWS OR CANCELLATIONS WITHIN AN HOUR OF DEPARTURE TIME.

*MEDICAL HISTORY

Could you be pregnant or are you attempting to become pregnant? _____ Do you regularly take prescription or non prescription medications? (with the exception of birth control) _____

Do you frequently suffer from motion sickness(seasick, carsick, etc.)? _____ History of diving accidents or decompression sickness? _____

Are you over 45 years of age and have one or more of the following?

- currently smoke a pipe, cigars or cigarette
- have a high cholesterol level
- have a family history of heart attacks or strokes

_____ History of recurrent back problems? _____

Have you ever had or do you currently have…

Asthma, or wheezing with breathing, or wheezing with exercise? _____ History of back surgery? _____

Frequent or severe attacks of hayfever or allergy? _____ History of diabetes? _____

Frequent colds, sinusitis or bronchitis? _____ History of back, arm or leg problems following surgery, injury or fracture? _____

Any form of lung disease? _____ Inability to perform moderate exercise(example: walking on mile within 12 minutes)? _____

Pneumothorax (collapsed lung)? _____ History of high blood pressure or take medication to control blood pressure? _____

History of chest surgery? _____ History of any heart disease? _____

Claustrophobia or agoraphobia(fear of closed or open spaces)? _____ Angina of heart surgery or blood vessel surgery? _____

Behavioral health problems? _____ History of heart attacks? _____

Epilepsy, seizures, convulsions or take medications to prevent them? _____ History of ear or sinus surgery? _____

Recurring migraine headaches or take medications to prevent them? _____ History of ear disease, hearing loss or problems with balance? _____

History of problems equalizing(popping) ears with airplane or mountain travel? _____ History of blackouts or fainting(full/partial loss of consciousness)? _____

History of bleeding or other blood disorders? _____ History of any type of hernia? _____

History of ulcers or ulcer surgery? _____ History of colostomy? _____

History of drug or alcohol abuse? _____

THE INFORMATION I HAVE PROVIDED ABOUT MY MEDICAL HISTORY IS ACCURATE TO THE BEST OF MY KNOWLEDGE.

*Participant Signature __________________________________________ Date _____________

*Parent/Guardian Signature _____________________________________ Date _____________

Could you be pregnant or are you attempting to become pregnant?	_____	Do you regularly take prescription or non prescription medications? (with the exception of birth control)	_____
Do you frequently suffer from motion sickness(seasick, carsick, etc.)?	_____	History of diving accidents or decompression sickness?	_____
Are you over 45 years of age and have one or more of the following? - currently smoke a pipe, cigars or cigarette - have a high cholesterol level - have a family history of heart attacks or strokes	_____	History of recurrent back problems?	_____
Have you ever had or do you currently have… Asthma, or wheezing with breathing, or wheezing with exercise?	_____	History of back surgery?	_____
Frequent or severe attacks of hayfever or allergy?	_____	History of diabetes?	_____
Frequent colds, sinusitis or bronchitis?	_____	History of back, arm or leg problems following surgery, injury or fracture?	_____
Any form of lung disease?	_____	Inability to perform moderate exercise(example: walking on mile within 12 minutes)?	_____
Pneumothorax (collapsed lung)?	_____	History of high blood pressure or take medication to control blood pressure?	_____
History of chest surgery?	_____	History of any heart disease?	_____
Claustrophobia or agoraphobia(fear of closed or open spaces)?	_____	Angina of heart surgery or blood vessel surgery?	_____
Behavioral health problems?	_____	History of heart attacks?	_____
Epilepsy, seizures, convulsions or take medications to prevent them?	_____	History of ear or sinus surgery?	_____
Recurring migraine headaches or take medications to prevent them?	_____	History of ear disease, hearing loss or problems with balance?	_____
History of problems equalizing(popping) ears with airplane or mountain travel?	_____	History of blackouts or fainting(full/partial loss of consciousness)?	_____
History of bleeding or other blood disorders?	_____	History of any type of hernia?	_____
History of ulcers or ulcer surgery?	_____	History of colostomy?	_____
History of drug or alcohol abuse?	_____
THE INFORMATION I HAVE PROVIDED ABOUT MY MEDICAL HISTORY IS ACCURATE TO THE BEST OF MY KNOWLEDGE. Participant Signature __________________________________________ Date _____________ Parent/Guardian Signature _____________________________________ Date _____________