DCM Liability Release - PDF Templates

Thursday, October 3, 2024

Medical Questionnaire/Liability Release

...in case of Emergency

Personal Information

Emergency Contact Name

r r

Your Name

Last Form

Nationality

Austria

Relationship (select one)

Friend

E Mail

ssimader@live.com

Diving Information

Select date of your confirmed dive

Saturday, October 5, 2024

Certification Level

Open Water Diver

Certifying Association

PADI

Certification #

Total logged dives

Date of last dive (DD-MM-YYYY)

Wednesday, October 2, 2024

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Medical Questionnaire

Cenote diving as well as any scuba diving activity requires good physical and mental health. There are a few medical conditions which can be hazardous while diving and those who have, or are predisposed to any of these conditions, should be evaluated by a physician. This Medical Questionnaire provides a basis to determine if you should seek out that evaluation.

This form is principally designed as an initial medical screen and serves to help avoid emergency situations. For your safety, and that of others who may dive with you, answer all questions honestly.

Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

Please answer the below questionnaire with either YES or NO.

1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance

2. I am over 45 years of age

2.B. I am over 45 years old AND

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

4. I have had problems with my eyes, ears, or nasal passages/sinuses

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease

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 disability

8. I have had back problems, hernia, ulcers, or diabetes

9. I have had stomach or intestine problems, including recent diarrhea

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam)

If you answered NO to all questions (with th

e exception of Nr. 2) above, no medical eval

uation is required. Please read and agree to

the statement below by signing it.

If you answered YES to any of the questions

(with the exception of Nr. 2), please downlo

ad the

as well as the

AND take all pages to your physician for a

medical evaluation. A Yes does not disqualif

y you from diving but participation in any d

iving activity requires a physician's approv

al.

By my electronic signature below, I certify

that I have answered all questions honestly,

and understand that I accept responsibility

for any consequences resulting from any que

stions I may have answered inaccurately or f

or my failure to disclose any existing or pa

st health conditions.

Fill in the Blanks

Full Name: LastFirst Name FormLast Name
Date: 03-10-2024Date

Signature:

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Liability Release

Further, I certify that

My physical and mental health are good for scuba diving. I understand that diving is a physically strenuous activity and that I will exert myself while diving. I affirm that if I am injured or killed as a result of cardiac events, panic, hyperventilation, oxygen toxicity, drowning or any other reason, I expressly assume all risks and that I will not hold the released parties responsible for the same. I affirm that I still wish to proceed with these diving activities and I assume all risks.

I will not dive under the influence of alcohol or drugs.

I will dive within the limits of my training and experience.

I know the internationally accepted recreational scuba diving systems-rules and I follow them.

I will listen to, respect, and follow the instructions of the guide.

Being a certified diver I am aware of the risks, rules, and procedures related to underwater activities using autonomous breathing devices internationally known as SCUBA, including but not limited to protocols for problem solutions and emergencies.

I am fully aware that I will perform these diving activities in "overhead" areas, which means NO POSSIBLE VERTICAL EXITS for the most part of the dive.

Before continuing please read the Summary of the Cenotes Dive Briefing which will be given to you before your dives so you can understand the different rules and requirements of cenote cavern diving.

I am fully aware that for this type of diving WITHOUT POSSIBLE VERTICAL EXITS it is mandatory to follow a nylon guideline as a visual reference to the determined route. I am fully aware that I won't be more than one meter (3 feet) away from it and will never lose the sight of it. I know that this line is the only certain reference to the exit. In the exceptional cases such as the dives of the sites known as The Pit and Angelita, where there is no guideline for the recreational single tank dives, I will never lose the sight of the direction of the surface.

I know the basic neutral buoyancy control techniques. I know that in an overhead environment those techniques are very important for human safety and conservation of the dive site. I will accept that the guide has the right to suspend my dive in any moment if the guide observes that I lack buoyancy control. In this case I agree that I do not have the right for any reimbursement.

I am fully aware that I should maintain at all times a horizontal position to avoid disturbing the sediment with movements of my fins or hands. I know that neutral buoyancy control is especially important in this type of diving environment, therefore I will combine in the best way possible the use of my buoyancy control device (BCD) and the dynamics of my lungs.

I am fully aware that in this kind of places, situations of partial or even total loss of visibility can occur. In such an event I know that the solution is to make immediate contact with the guideline and head for the direction of the exit following the line with precaution and protecting my body and my equipment.

I know and understand the strategy for air management known as "Rule of Thirds" applied or adapted to this kind of dives. I am fully aware that I must let my guide know whenever the first third of my air pressure has been consumed, to proceed or continue the process of exiting. I know that the first third of the air pressure is to enter, the second to exit, and the third must be preserved as the reserve for safety or a possible emergency.

I know the three basic light signals: (i) t

he OK signal, that consists in making circl

es with the light to make a question and to

answer; (ii) the attention signal, that co

nsists in moving the light from up and down

with a slow movement, and (iii) the proble

m or emergency signal that consists in movi

ng the light fast from side to side.

I also know that the hand signal with a closed fist and the thumb pointing up that in open water diving means ascend, for this kind of diving means "exit."

I assume the responsibility of taking care of the equipment that I will use. I accept to replace it or pay for it in case of damage or loss.

I assume the total responsibility of my behavior during scuba diving and related activities.

I ascert that I do not suffer any physical disability and that I am able to carry my scuba equipment including my tank from the divers' parking area to the water entrance (at some sites approximately 8o meters / 250 feet with steps). In any other case, I will inform the dive center ahead of time of any disabilities. In case of a needed "Porter" loading service, I agree to pay US$25 extra for the additional services. I am aware that my guide will not carry my tanks.

By signing this document I exempt the guide, the dive center, and the people in charge of the dive sites from any responsibility or liability that might be connected to any event that can occur because of my behavior or any fortuitous cause.

By my eSignature below, I certify that I have read and understand the above statement presented to me in which I was informed of the established safe diving practices and the risks involved; that I accept its term; that I am legally competent to sign it; and that I sign it voluntarily.

Further, by my eSignature below, I certify that I allow Dive Cenotes Mexico to store my personal data and to share it in electronic or printed format with involved supporting facilities in case of an emergency.

Full Name: Last Form
Date: 03-10-2024

Signature: