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t Participant Record (confidential information) PLEASE PRINT CLEARLY. Name PADI Seal Team Statement_____________________________________________________ Birthdate _______________ Age _______ Address _______________________________________________________________________________________ City _________________________________________________ State/Province ___________________________ Country ________________________________________________________ Zip/Postal Code ________________ Home Phone (_____) ______________________________ email _________________________________________ Emergency contact _______________________________________ Relationship___________________________ Primary Phone (_____) _____________________________  Home  Work  Cell Secondary Phone (_____) _____________________________  Home  Work  Cell How did you hear about us? _______________________________________________________________________ MEDICAL QUESTIONNAIRE To the participant and parent: Please answer YES or NO to any of the following items to accurately reflect the participant’s past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval before being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician.  Yes  No I am currently suffering from a cold or congestion.  Yes  No I have a history of respiratory problems or disease.  Yes  No I have had asthma, emphysema or tuberculosis.  Yes  No I currently have an ear infection.  Yes  No I have recurrent ear problems, ear disease or surgery.  Yes  No I have a history of sinus problems.  Yes  No I have had problems equalizing (popping) my ears with airplane or mountain travel.  Yes  No I am diabetic.  Yes  No I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack).  Yes  No I have a history of seizures, dizziness or fainting.  Yes  No I have a nervous system disorder.  Yes  No I have behavioral health, mental or psychological disorders (panic attack, fear of closed or open spaces).  Yes  No I have recurrent back problems, history of back or spinal surgery.  Yes  No I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial).  Yes  No I have recently had an operation or illness.  Yes  No I am under the care of a physician or have a chronic illness. — over — PRODUCT NO. 10264 Version 1.2 (03/05) © International PADI, Inc. 2005 PADI SEAL TEAM ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT Please read carefully and fill in all blanks before signing. I, _____________________________________, parent/guardian and __________________________________, participant, hereby affirm that we are aware of and understand there are inherent hazards associated with skin diving and scuba diving which may result in serious injury or death. We understand there are certain risks associated with aquatic activities conducted in and around a swimming pool or confined water dive site, and we expressly assume the risk of said injuries. We understand the PADI Seal Team program is a series of AquaMissions which will be conducted in a swimming pool or confined water dive site. We understand that my child may choose to participate in one or all of these AquaMissions. These AquaMissions include, but are not limited to, five (5) core AquaMissions involving the introduction of basic dive skills and ten (10) specialty AquaMissions including, but not limited to, Creature ID Specialist, Environmental Specialist, Inner Space Specialist, Navigation Specialist, Night Specialist, Search and Recovery Specialist, Skin Diver Specialist, Snapshot Specialist, Team Safety Specialist and Wreck Specialist We understand and agree that this Release encompasses and applies to all the PADI Seal Team AquaMissions, as described above, in which my child chooses to participate. Further, we hereby state and agree that this Release will be effective and valid for all PADI Seal Team activities in which my child participates for a period of one year from the initial date on which I execute this Release. We understand that diving with compressed air involves certain inherent risks and my child will be exposed to these risks. Decompression sickness, embolism or other hyperbaric injuries can occur which require treatment in a recompression chamber. We further understand that this activity may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. We still choose to proceed with this activity in spite of the absence of a recompression chamber in proximity to the activity site. We understand and agree that neither the dive professionals conducting this activity, nor the facility through which this activity is conducted, _________________________________________, nor International PADI, Inc., 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 my child, me, my family, our heirs or assigns that may occur as a result of my child’s participation in this activity or as a result of the negligence of any party, including the Released Parties, whether passive or active. We further understand that scuba diving is a physically strenuous activity and that my child will be exerting him/herself during this activity and that if my child is injured as a result of heart attack, panic, hyperventilation, etc., that we expressly assume the risk of said injuries to my child. We affirm that we will not hold the above listed individuals or companies responsible for the same. In consideration of my child being allowed to participate in this activity we hereby personally assume all risks in connection with the activity for any harm, injury or damage that may befall my child while participating in the activity, including all risks connected therewith, whether foreseen or unforeseen. We further release and hold harmless said activity and the Released Parties from any claim or lawsuit by my child, me, or my family, or our estate, heirs or assigns, arising out of my child’s participation in this activity. We understand and agree this Release is divisible, and any portion herein held to be in violation of any applicable statutes or regulations or any governmental agency having jurisdiction shall affect only that portion held to be invalid or inoperative, and the remaining portions of this Release shall remain in full force and effect. I further state that I am of lawful age and legally competent to sign this Assumption of Risk and Liability Release Agreement, and as the parent am providing written consent for the participation of my child. We understand that the terms herein are contractual and not a mere recital and that we have signed this Release of our own free act. I, ___________________________________, PARENT/GUARDIAN AND _____________________________________,PARTICIPANT, BY THIS INSTRUMENT DO EXEMPT AND RELEASE THE DIVE PROFESSIONALS CONDUCTING THIS ACTIVITY, THE FACILITY THROUGH WHICH THIS ACTIVITY IS CONDUCTED, AND INTERNATIONAL PADI, INC., AND ALL RELATED ENTITIES 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. WE HAVE FULLY INFORMED OURSELVES OF THE CONTENTS OF THIS ASSUMPTION OF RISK AND LIABILITY RELEASE AGREEMENT BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF, MY CHILD, AND OUR HEIRS. _________________________________________________ ___________________ Signature of Participant Date (day/month/year) _________________________________________________ ___________________ Signature of Parent/Guardian Date (day/month/year)