Diver Questionnaire & Waiver Form

Dive Shop Intake Form

Updates

Diver's Intake Questionnaire & Waiver of Liability Agreement

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

If you have any concerns about your diving fitness not represented on this form, consult your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. For your safety, and that others who may dive with you, answer all questions honestly.

First Name

Last Name

Address

City

State

Zip Code

Birthdate

Phone Number

Scheduled Dive Date

Valid Identification (Upload)

Choose File

Diver's ID (Upload)

Choose File

Emergency Contact

Phone/Mobile

Diver's Current Profile

Dive Agency

Certification level

Dives Logged

Date of Last Dive

Could you be pregnant or are you attempting to become pregnant?

Yes

I am taking prescription medications (with the exception of birth control)

Yes

I have had problems with my lungs/breathing, heart, blood.

Yes

I am over 45 years of age and have high cholesterol level or a family history of heart attacks or strokes.

Yes

I struggle to perform moderate exercise, or I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.

Yes

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

Yes

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.

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Additional Information

Scuba Diving Medical Statement

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 scuba diving. Your signature on this statement is required in order to participate in the scuba diving training program and/or scuba diving activities offered by Infinity Divers.

Read and discuss this statement and fill the form related to your medical history prior to signing it. If you are a minor, you must have this statement signed by a parent or guardian.If you have any additional questions regarding this medical statement, review them with the instructor before signing.

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

Release of Liability and Express Assumption of Risk

I hereby affirm that I have been advised and informed of the inherent hazards of scuba diving. I understand and agree that neither my instructor(s), Infinity Divers the facility through which I receive my instruction/ I scuba diver , nor any of the respective employees, officers or subcontractors, may be held liable or responsible in any way for any injury, death, or other damages to me or my family heirs, or beneficiaries that may occur as a result of my participation in this diving program.

I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. I understand that the terms herein are contractual and not mere recital; and I have signed this document of my own free will.

I have read and agree to the Terms and Conditions and Privacy Policy

Today's Date

Signature

Sign Here

FAQ's - Diver's Intake Questionnaire & Release Liability Agreement

Who is required to complete and sign the Release & Waiver of Liability Agreement?

All island guests who are participating in an excursion or tour with Discover Roatan Excursions and Tours is required to complete, sign, and submit this waiver form.

This includes minors and or individuals riding along with family or friends. The agreement must be completed and submitted by each individual. Parents or legal guardians will sign and submit the waiver on behalf of the minor.

How long do I have to return the completed Release & Waiver of Liability Agreement?

We recommend you complete and submit the agreement upon receiving it.

Island guests who have not provided the executed agreement prior to their arrival will delay the start of their shore excursion and will not be allowed to continue with the purchased tour until the agreement is completed and signed in person.

All Inclusive

Animal Parks

ATV

Beach Breaks

Brady's Cay

Combination

Dolphin Encounter

Fishing Charters

Golfing

Horseback Riding

Island Tours

Little French Key

Pristine Bay Resort

Roatan SCUBA

Snorkel Tours

Spa & Wellness

Underwater Adventures

Ziplines

All Inclusive

Animal Parks

ATV

Beach Breaks

Brady's Cay

Combination

Dolphin Encounter

Fishing Charters

Golfing

Horseback Riding

Island Tours

Little French Key

Pristine Bay Resort

Roatan SCUBA

Snorkel Tours

Spa & Wellness

Underwater Adventures

Ziplines

Diver Questionnaire & Waiver Form

Diver's Intake Questionnaire & Waiver of Liability Agreement

Diver's Current Profile

Scuba Diving Medical Statement

Release of Liability and Express Assumption of Risk

FAQ's - Diver's Intake Questionnaire & Release Liability Agreement

All Inclusive

Animal Parks

ATV

Beach Breaks

Brady's Cay

Combination

Dolphin Encounter

Fishing Charters

Golfing

Horseback Riding

Island Tours

Little French Key

Pristine Bay Resort

Roatan SCUBA

Snorkel Tours

Spa & Wellness

Underwater Adventures

Ziplines

Travel Agency Only

Please enter your email and CLIA/IATA number, you will be redirected.