潛水課程

医疗声明 & 未成年参加者监护人同意声明

本人于潜庄潜水渡假中心参加浮潜、体验潜水、水肺潜水训练课程或浮潜、体验潜水、水肺潜水活动。在此当事人本人、当事人之法定代理人、继承人及亲属都明确认知：

浮潜、体验潜水、水肺潜水是一项具有潜在风险的活动，其风险可能包括受伤、死亡及财物之损失。同时，当事人亦知悉，万一因使用压缩空气而受伤时，将需要接受再压舱的治疗，而前往再压舱治疗机构可能需要经过长途跋涉。

于参加上述课程或活动之期间，如因当事人本身之疏失，未能遵守课程规定或潜水活动相关之安全操作程序，导致当事人任何形式之财物损失、伤害甚至死亡，以及当事人之法定代理人、继承人及其亲属之财产权利损之，当事人愿自行承担所有的赔偿责任。

当事人并在此认知，所受的伤害可能来自于急救过程。于签署本「切结同意书」的同时，应于法律允许的情况下，尽量扩大其适用范围及涵盖项目。

当事人以详阅本「切结同意书」并完全了解其内容，同时也了解于签署后所放弃之权利，并自愿承担其法律责任。这份同意书的签署，是于当事人自由意愿、无任何诱因以及不实承诺的情况下，无条件同意解除受让人法律上的责任。在此之前，当事人确实曾与潜水业者讨论过各种浮潜、水肺潜水课程或活动中，可能发生之潜在风险。

医疗声明：

本人了解以下叙述之状况均会影响潜水时安全，如果其中有任何一项答案為『是』，在您參加此水肺潛水之前，我們必須要求您諮詢醫師的建議。

• 您是否可能怀孕或打算怀孕？
• 您是否有定期服用医嘱药物？（避孕药除外）
• 您是否在45岁以上并有下列其中一项？
• 目前有抽烟斗，雪茄或香烟。
• 胆固醇指数很高
• 家族中有心脏病或中风的病历
• 目前在就医诊治
• 高血压
• 糖尿病，即使有作饮食控制

您过去或是现在是否有...

• 气喘，或呼吸发出气喘声，或运动时发出气喘声？
• 常常发生或是罹患严重的花粉症或过敏症？
• 经常感冒，鼻窦炎或支气管炎？
• 任何肺部疾病种类。
• 气胸（胸部萎陷）
• 其他胸腔疾病或胸部手术
• 行为上的健康问题。心理或精神问题（恐慌攻击，害怕封闭或是开放场所）
• 癫痫，发病，抽搐或服用预防这类疾病的药物？
• 复发性偏头痛或服用预防药物？
• 眼前发黑或昏厥（完全/部份失去反应）？
• 您是否常常晕船，晕车，晕机等？
• 需要医疗的腹泻或脱水
• 潜水意外或减压病？
• 有复发性背部疾病的病史？
• 无法从事温和的运动（在12分钟以内步行1.6公里/ 1英里）
• 在过去五年内有因丧失意识而头部受伤？
• 复发性背部毛病？
• 糖尿病？
• 因手术，受伤或骨折所导致的背部，手臂或脚部问题？
• 高血压或服药控制血压
• 心脏病？
• 心脏病发病？
• 心绞痛或心脏手术或血管手术？
• 静脉窦手术？
• 耳朵疾病，听力丧失或平衡问题？
• 在飞机或高山旅游时平衡耳朵的问题？
• 复发性耳朵问题？
• 失血或其他血液疾病的病历？
• 疝气？
• 溃疡病历或溃疡手术？
• 结肠造口术（人工肛门）？
• 在过去五年内有滥用药物或酒精？

Medical Statement & Guardian Consent Statement

Read the following paragraphs carefully. This statement informs you of some potential risks involved in scuba diving and of the conduct required of you during the Discover Scuba Diving program. Your signature is required to participate in the program. If you are a minor, you must have the Participant Statement signed by your parent or guardian. You will also need to learn from the instructor the most important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury or death. You must be thoroughly instructed in its use under the direct supervision of a qualified instructor to use it safely.

I hereby affirm that I am aware that skin and scuba diving have inherent risks that may result in serious injury or death.

I understand that diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injuries can occur that require treatment in a recompression chamber. I further understand that the open water diving trips which are necessary to participate in this program 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 such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site.

I understand and agree that neither my instructor(s), nor Dive Village Diving Resort, nor any of its respective employees, officers, agents, contractors 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 me, my family, estate, heirs or assigns that may occur as a result of my participation in scuba diving or as a result of the negligence of any party, including the Released Parties, whether passive or active.

I further release, exempt and hold harmless said Released Parties from any claim or lawsuit by me, my family, estate, heirs, or assigns, arising out of my enrollment and participation in scuba diving including both claims arising during these activities or after I receive my certification.

I also understand that skin and scuba diving are physically strenuous activities and that I will be exerting myself during this program, and that if I am injured as a result of a heart attack, panic, hyperventilation, drowning or any other cause, that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same. 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 the terms herein are contractual and not a mere recital, and that I have signed this document of my own free act and with the knowledge that I hereby agree to waive my legal rights.



DISCOVER SCUBA DIVING MEDICAL QUESTIONNAIRE
The purpose of this medical questionnaire is to find out if you should be examined by a doctor before participating in recreational scuba diving. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of a physician.
Please check the following questions about your past and present medical history. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving.

• Do you currently have an ear infection?
• Do you have a history of ear disease, hearing loss or problems with balance?
• Do you have a history of ear or sinus surgery?
• Are you currently suffering from a cold, congestion, sinusitis or bronchitis?
• Do you have a history of respiratory problems, severe attacks of hay fever or allergies, or lung disease?
• Have you had a collapsed lung (pneumothorax) or history of chest surgery?
• Do you have active asthma or history of emphysema or tuberculosis? Are you currently taking medication that carries a warning about any impairment of your physical or mental abilities?
• Do you have behavioral health, mental or psychological problems or a nervous system disorder?
• Are you or could you be pregnant?
• Do you have a history of colostomy?
• Do you have a history of heart disease or heart attack, heart surgery or blood vessel surgery?
• Do you have a history of high blood pressure, angina, or take medication to control blood pressure?
• Are you over 45 and have a family history of heart attack or stroke?
• Do you have a history of bleeding or other blood disorders?
• Do you have a history of diabetes?
• Do you have a history of seizures, blackouts or fainting, convulsions or epilepsy or take medications to prevent them?
• Do you have a history of back, arm or leg problems following an injury, fracture or surgery?
• Do you have a history of fear of closed or open spaces or panic attacks (claustrophobia or agoraphobia)?