Mykonos Diving Center

MYKONOS DIVING CENTER REGISTRATION FORM

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FD - Fun Diver & Snorkeling Statement
DSD - Discover Scuba Diving Statement
DSD Test and Equipment Form

Discover Scuba Diving

Fun Diver

Reservation Date *

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Direct: Either on your own or though internet booking on our website
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Transfer: Did we provide your transfer to our Diving Center?YesNo

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STUDENT INFOMATION

DIVER INFOMATION

First Name *

Last Name *

Date of Birth *

Name *

Participant Signature *

Email *

Address *

City *

State/Province

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Occupation

Age *

Sex *MF

Father's Name

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Statement of Risks and Liability

I , {name-13-first-name} {name-13-last-name} , hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. I affirm I have read and understand the Safe Diving Practices and have had any questions answered to my satisfaction. I understand the importance and purposes of these established practices. I recognise they are for my safety and well-being, and that failure to adhere to them can place me in jeopardy when diving. I understand that diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. I further understand that this programme may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with this programme in spite of the absence of a recompression chamber in proximity to the dive site. The information I have provided about my medical history on the Medical Questionnaire is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions. I further understand that skin diving and scuba diving are physically strenuous activities and that l will be exerting myself during this programme. I further state that I am of lawful age and legally competent to sign this Statement of Risks and Liability, or that I have acquired the written consent of my parent or guardian. Neither the teaching instructor(s), Kostas Sgourakis, the facility through which this training is offered, Mykonos Diving Center / Dive Adventures, PADI lnternational Ltd., or PADl Americas, lnc., accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any manner or condition under my control which amounts to my own contributory negligence. ln the absence of any negligence or other breach of duty by the teaching instructor(s) , Kostas Sgourakis, the facility through which this training is offered, Mykonos Diving Center / Dive Adventures , PADI lnternational Ltd., or PADl Americas, lnc., my participation in this diving course is entirely at my own risk.

I {name-13-first-name} {name-13-last-name} have fully informed myself of the contents of this Statement of Risks and Liability by reading it before signing it

STATEMENT OF RISKS AND LIABILITY

Please read carefully and fill in all blanks before signing.

This is a statement in which you are informed of the risks of skin and scuba diving. The statement also sets out the circumstances in which you participate in the diving programme at your own risk.
Your signature on this statement is required as proof that you have received and read this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then please discuss it with your instructor. If you are a minor, a parent or guardian must also sign this
form.

WARNING Skin and scuba diving have inherent risks, which may result in serious injury or death.
Diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. Open water diving trips, which are necessary for training and for certification, may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. Skin and scuba diving are physically strenuous activities and you will be exerting yourself during this diving programme.
You must advise truthfully and fully inform the dive professionals and the facility through which this programme is offered of your medical history.

EXCLUSION OF LIABILITY

I understand and agree that neither the dive professionals conducting this programme, Kostas Sgourakis, nor the facility through which this programme is conducted, Mykonos Diving Center / Dive Adventures, nor PADI International Ltd., nor PADI Americas, Inc., nor their affiliate or subsidiary corporations, nor any of their respective
employees, officers, agents or assigns (hereinafter referred to as “Released Parties”) accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any matter or condition under my control that amounts to my own contributory negligence.

In the absence of any negligence or other breach of duty by the dive professionals conducting this programme, Kostas Sgourakis, the facility through which this programme is offered, Mykonos Diving Centre / Dive Adventures, PADI International Ltd., PADI Americas, Inc., and all released entities and released parties as defined above, my participation in this diving programme is entirely at my own risk.

I {name-13-first-name} {name-13-last-name} acknowledge receipt of this Statement and have read all of the terms before signing this Statement.

Participant Signature *

Date *

Signature of Parent/Guardian (if applicable)

Date

Certification Agency *

Please specify *

Certification Agency

Level *

Year Qualified *

Date of Last Dive *

Total Number of Dives *

Dive CheckYesNo

EMERGENCY CONTACT INFORMATION

In case of emergency, contact: (Please supply as much information as you can)

Name *

Relationship *

Residence Phone *

Work Phone

Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. 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 with 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. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.

Directions

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.
Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. *YesNo

I am over 45 years of age. *YesNo

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. *YesNo

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

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

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

I am currently undergoing treatment (or have required treatment within the last fve years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. *YesNo

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

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

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

Box A - I have/have had

Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung). *YesNo

Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise. *YesNo

A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition. *YesNo

Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *YesNo

A diagnosis of COVID-19 *YesNo

Box B – I am over 45 years of age AND:

I currently smoke or inhale nicotine by other means *YesNo

I have a high cholesterol level. *YesNo

I have high blood pressure *YesNo

I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). *YesNo

Box C – I have/have had:

Sinus surgery within the last 6 months *YesNo

Ear disease or ear surgery, hearing loss, or problems with balance. *YesNo

Recurrent sinusitis within the past 12 months. *YesNo

Eye surgery within the past 3 months. *YesNo

Box D – I have/have had:

Head injury with loss of consciousness within the past 5 years *YesNo

Persistent neurologic injury or disease. *YesNo

Recurring migraine headaches within the past 12 months, or take medications to prevent them. *YesNo

Blackouts or fainting (full/partial loss of consciousness) within the last 5 years *YesNo

Epilepsy, seizures, or convulsions, OR take medications to prevent them. *YesNo

Box E – I have/have had:

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *YesNo

Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *YesNo

Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care. *YesNo

An addiction to drugs or alcohol requiring treatment within the last 5 years. *YesNo

Box F – I have/have had:

Recurrent back problems in the last 6 months that limit my everyday activity. *YesNo

Back or spinal surgery within the last 12 months. *YesNo

Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months. *YesNo

An uncorrected hernia that limits my physical abilities. *YesNo

Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *YesNo

Box F – I have/have had:

Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *YesNo

Dehydration requiring medical intervention within the last 7 days. *YesNo

Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *YesNo

Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *YesNo

Active or uncontrolled ulcerative colitis or Crohn’s disease. *YesNo

Bariatric surgery within the last 12 months. *YesNo

If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement
below by signing and dating it.

Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences
resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.

Signature *

Date *

First Name *

Last Name *

Participant Name *

Birthdate *

I have had asthma, emphysema or tuberculosis. *YesNo

I currently have an ear infection. *YesNo

Instructor Name *

Diving Center *

Diver Medical | Medical Examiner’s Evaluation Form

{name-13-first-name} {name-13-last-name} | {date-3}

The above-named person requests your opinion of his/her medical suitability to participate in recreational scuba diving or freediving training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas rele-
vant to your patient as part of your evaluation.

Evaluation ResultApproved – I find no conditions that I consider incompatible with recreational scuba diving or freediving.Not approved – I find conditions that I consider incompatible with recreational scuba diving or freediving.

Signature *

Date *

Medical Examiner's Name

Clinical Degrees/Credentials

Address

City

Country

Phone

Bubblemaker Statement |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.

I am currently suffering from a cold or congestion. *YesNo

I have a history of respiratory problems or disease. *YesNo

I have recurrent ear problems, ear disease or surgery. *YesNo

I have a history of sinus problems. *YesNo

I have had problems equalizing (popping) my ears with airplane or mountain travel. *YesNo

I am diabetic. *YesNo

I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack). *YesNo

I have a history of seizures, dizziness or fainting. *YesNo

I have a nervous system disorder. *YesNo

I have behavioural health, mental or psychological disorders (panic attack, fear of closed or open spaces). *YesNo

I have recurrent back problems, history of back or spinal surgery. *YesNo

I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial). *YesNo

I have recently had an operation or illness. *YesNo

I am under the care of a physician or have a chronic illness. *YesNo

BUBBLEMAKER STATEMENT OF RISKS AND LIABILITY

Please read carefully and fill in all blanks before signing.

This is a statement in which you are informed of the risks of skin and scuba diving. The statement also sets out the circumstances in which your child participates in the diving programme at your child’s own risk.

Your signature on this statement is required as proof that you and your child have received and read this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then please discuss it with your child’s instructor.

WARNING

Skin and scuba diving have inherent risks which may result in serious injury or death.

Diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber and your child will be exposed to these risks. This programme may be conducted at a site which is remote, either by time or distance or both, from such a recompression chamber

Skin and scuba diving are physically strenuous activities and your child will be exerting themselves during this diving programme. You must advise truthfully and fully inform the dive professionals and the facility through which this programme is offered of your child’s medical history.

EXCLUSION OF LIABILITY

I understand and agree that neither the dive professionals conducting this programme, nor the facility through which this programme is conducted,
Mykonos Diving Center, nor PADI International Ltd., nor PADI Americas, Inc., nor their affiliate or subsidiary
orporations, nor any of their respective employees, officers, agents or assigns (hereinafter referred to as “Released Parties”) accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any matter or condition under my control that amounts to my own contributory negligence.
In the absence of any negligence or other breach of duty by the dive professionals conducting this programme, the facility through which this programme is offered, Mykonos Diving Center, PADI International Ltd., PADI Americas, Inc., and all related entities and released parties as defined above, my participation in this diving programme is entirely at my own risk.

I acknowledge receipt of this Statement and have read all of the terms before signing this Statement.

First Name *

Last Name *

Participant Name *

Signature *

Date *

Signature of Parent/Guardian (where applicable)

Date

Discover Scuba Diving Knowledge and Safety Review

To continue your Discover Scuba Diving Experience, you must complete this review under the directiob of your PADI Proffessional before getting in the water.

Check the appropriate box in response to each question.

1. Upon completing this experience, I will be qualified to dive independently without a certified professional guiding me.TF

2. To equalize my ears and sinus air spaces during descent, I will need to blow gently against pinched nostrils.TF

3. I should equalize every few metre/few feet while descendingTF

4. If I have discomfort in my ears and sinuses during descent, I should continue downward.TF

5. Underwater, I should breath slowly, deeply, continuously and never hold my breath.TF

6. I should add air to my buoyancy control device (BDC) to float at the surface.TF

7. My air gague indicates how much air I have in my cylinder and I must look at it ofter, and whenever my instructor asks me to.TF

8. I should not touch, tease, or harass an underwater organism since I may harm it or it may harm me.TF

9. I should stay close to the PAD Professional during my Discover Scuba Diving experience and signal if something is wrongTF

Participant Statement: I have had this Review explained to me and I now understand any questions I may have answered incorrectly. I acknowledge and accept that these practices are intended to increase my safety and comfort during the experience.

Participant's Signature *

Date *