Medical Questionnaire & Liability Waiver

Medical Questionnaire & Liability Waiver

MEDICAL HISTORY (please check boxes to say you’ve read paragraphs):

Please read the following medical questions carefully YES or NO regarding your past & present medical history. If unsure answer YES.

If you answer YES you MUST provide further information in the box at the end of this section (about condition/injury/history, list medications taken/used etc.) *

Pregnancy: Are you pregnant or planning to be pregnant?
Neurological: Any history of seizure disorder; convulsions fainting or fits; hallucinations; schizophrenia; brain surgery; stroke, black-outs; severe migraine headaches; aneurysm or brains blood vessels; other
Cardiovascular (Heart & Blood) Conditions: Heart attack; heart surgery, irregular heart beat, uncontrolled elevated blood pressure; uncontrolled bleeding or blood disorders; other
Asthma: Asthma history or attacks; History of wheezing caused by exercise, cold, anxiety, fatigue etc; Any condition requiring medication and/or use of inhaler to control wheezing; other
Lungs: Any history of collapsed lungs, spontaneous or by injury: cysts; air pockets; damaged lung tissue, emphysema; any problem that interferes with your ability to breathe
Medications: With the exception of birth control or anti-malarial, anything taken on a regular basis either over-the-counter or prescription *
Diving Accidents: Any history of diving accidents or decompression illness
Medical: Any physical and/or emotional condition not mentioned that might affect your safety in an underwater environment or affect your judgement under times of physical or emotional stress
Any allergies?
Diabetes - current or history
  • I hereby declare that I understand and agree that neither Equalize Training Company, its employees or associates, the pool owners/operators/staff (hereinafter referred to as Released Parties) may be held liable or responsible in any way for any injury, death, or other damages to myself, my family, estate, heirs or assigns that may occur as a result of my participation in this B.E.T Course, either as a result of negligence, omission or carelessness by the Released Parties, whether passive or active, known or unknown, foreseen or unforeseen.
  • I understand the dangers associated with the consumption of drugs, including alcohol and the smoking of tobacco, before, during and after the B.E.T Course , and recognise that consumption of such products may impair my judgment and/or motor skills as well as increase my predisposition to succumbing to blackouts. With this understanding, I assume full responsibility for any injury, loss or damage associated with my consumption of products mentioned in this paragraph.
  • I understand and agree that aquatic activities can be physically strenuous and may potentially pose a test of a person’s physical and mental limits, carrying with it the potential for death, serious injury, and property damage. I understand & agree that the development of B.E.T abilities naturally requires an individual & variable period of adaptation to such physiological factors as hypoxia (low tissue oxygen levels), hypercapnia (elevated tissue carbon-dioxide levels).
  • I declare that I am in good mental & physical fitness for B.E.T and that I have no physical or medical condition or impairment which would endanger or interfere with my participation, or that of others, in any B.E.T Course. If I am unsure or if advised by B.E.T staff I will seek medical advice & provide a Medical Certificate of Approval for participation.
  • I undertake to immediately notify in writing, an Equalize Training Company staff member of any change in my medical status, including medical conditions, general health and any surgical procedures or condition(s) that are likely to affect my fitness to participate further in the course.
  • I understand and agree that the organisers of B.E.T Courses reserve the right to accept or reject applications on medical grounds at its discretion.
  • I understand, agree and take full responsibility for missed attendance due to illness, injury, insufficiencies etc.
  • I understand and agree that all the terms herein are contractual, they are not a mere recital, and my signing of this document is done of my own free act of will and in so doing, I waive my legal rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid that provision shall be severed from this Agreement. The reminder of this Agreement will then be constructed as though the unenforceable provision had never been contained therein.
  • I state that I am or will be of 18 years of age or lawful age and legally competent to sign this liability release, or that I have the written consent of **one/both parent(s) or legal guardian(s) to engage in a B.E.T Course run by Equalize Training Company under the conditions of this waiver as stipulated by their agreement below.

** If the signature of only one parent/legal guardian is obtained, the legal guardian who signs insures with his/her signature that he/she is acting with the permission of the other parent/legal guardian or that he/she has the sole custody for the minor.*