Name *

Email *

Phone *

Date of Birth *

Gender * Male
Female
X - Non-binary
Prefer not to say

Occupation *

Address *

City/Town/Suburb *

State/County * Select State ... QLD NSW VIC ACT TAS SA WA NT INTERNATIONAL

Zip/Post Code *

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Email *

Relationship to Participant *

MEDICAL HISTORY QUESTIONNAIRE

WARNING: Breath-Hold training in an aquatic environment can be hazardous. The aquatic environment i.e. swimming pool, beach pool or ocean, is a dynamic medium that can be physically demanding and mentally challenging. The aquatic environment may expose you to unusual mental and physical stressors in a short period of time that if left unchecked or taken to extremes, may result in injury or death unknowingly. There is also considerable sensory deprivation i.e vision, hearing, touch and balance all of which can be disturbed and restricted and the effects are exacerbated by certain medical conditions. Failure to account for these conditions prior to engaging in Breath Enhancement Training activities may endanger your health, your life, and the safety of any person you may train with. Check the box to confirm acceptance. *

MEDICAL HISTORY (please check boxes to say you’ve read paragraphs): The purpose of the following questions is to find out if your doctor should examine you before participating in Breath Enhancement Training (B.E.T). Your signature on this statement is required for you to participate in B.E.T programs. A positive response to a question does not necessarily disqualify you from participating, it just means that there is a pre-existing condition that may affect your safety and Equalize Training Company Pty Ltd will advise if you must seek the advice of your physician prior to engaging in our programs (and supply us with a medical certificate). Nevertheless, some medical conditions are too risky and will, consequently, preclude you from participation.

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? * Yes
No

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 * Yes
No

Cardiovascular (Heart & Blood) Conditions: Heart attack; heart surgery, irregular heart beat, uncontrolled elevated blood pressure; uncontrolled bleeding or blood disorders; other * Yes
No

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. * Yes
No

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 * Yes
No

Medications: With the exception of birth control or anti-malarial, anything taken on a regular basis either over-the-counter or prescription * Yes
No

Diving Accidents: Any history of diving accidents or decompression illness * Yes
No

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 * Yes
No

Any allergies? * Yes
No

Diabetes - current or history * Yes
No

Please provide a Full Description of Medical Conditions, injury or history and/or Medications taken/used when answered YES in previous questions. If you answered NO to all, please write NONE in the box, thank you. *

WAIVER: LIABILITY RELEASE, ASSUMPTION & ACCEPTANCE OF RISK: Please read each paragraph before proceeding. Booking this event accepts the below declaration in its entirety. Equalize Training Company’s Breath Enhancement Training course will herein after be referred to as B.E.T.

• 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.
*

MEDICAL HISTORY & WAIVER DECLARATION: This declaration and your responses to the medical questionnaire are a confidential document between yourself and the Breath Enhancement instructor/supervisor. If you have any questions regarding this Medical Questionnaire or the Medical Declaration, review them with a B.E.T staff member before signing. *

I hereby affirm that I have provided accurate information about my medical history to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. If I suffer from any such condition I have or will seek professionally informed opinion on these medical conditions which may predispose me to a greater risk than normal whilst involved in Breath Enhancement Training. *

PARTICIPANT SIGNATURE - TYPE FULL NAME TO CONFIRM YOU AGREE WITH THE ABOVE *

PARENT(s)/GUARDIAN(s) SIGNATURE if <18 years of age - TYPE FULL NAME TO CONFIRM YOU AGREE WITH THE ABOVE ** 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.