潜水课程

醫療聲明 & 未成年參加者監護人同意聲明

本人於潛莊潛水渡假中心參加浮潛、體驗潛水、水肺潛水訓練課程或浮潛、體驗潛水、水肺潛水活動。在此當事人本人、當事人之法定代理人、繼承人及親屬都明確認知：

浮潛、體驗潛水、水肺潛水是一項具有潛在風險的活動，其風險可能包括受傷、死亡及財物之損失。同時，當事人亦知悉，萬一因使用壓縮空氣而受傷時，將需要接受再壓艙的治療，而前往再壓艙治療機構可能需要經過長途跋涉。

於參加上述課程或活動之期間，如因當事人本身之疏失，未能遵守課程規定或潛水活動相關之安全操作程序，導致當事人任何形式之財物損失、傷害甚至死亡，以及當事人之法定代理人、繼承人及其親屬之財產權利損之，當事人願自行承擔所有的賠償責任。

當事人並在此認知，所受的傷害可能來自於急救過程。於簽署本「切結同意書」的同時，應於法律允許的情況下，盡量擴大其適用範圍及涵蓋項目。

當事人以詳閱本「切結同意書」並完全了解其內容，同時也瞭解於簽署後所放棄之權利，並自願承擔其法律責任。這份同意書的簽署，是於當事人自由意願、無任何誘因以及不實承諾的情況下，無條件同意解除受讓人法律上的責任。在此之前，當事人確實曾與潛水業者討論過各種浮潛、水肺潛水課程或活動中，可能發生之潛在風險。

醫療聲明：

本人了解以下敘述之狀況均會影響潛水時安全，如果其中有任何一項答案為『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。

• 您是否可能懷孕或打算懷孕？
• 您是否有定期服用醫囑藥物？（避孕藥除外）
• 您是否在45歲以上並有下列其中一項？
• 目前有抽煙斗、雪茄或香煙。
• 膽固醇指數很高
• 家族中有心臟病或中風的病歷
• 目前在就醫診治
• 高血壓
• 糖尿病，即使有作飲食控制

您過去或是現在是否有...

• 氣喘，或呼吸發出氣喘聲，或運動時發出氣喘聲？
• 常常發生或是罹患嚴重的花粉症或過敏症？
• 經常感冒、鼻竇炎或支氣管炎？
• 任何肺部疾病種類。
• 氣胸（胸部萎陷）
• 其他胸腔疾病或胸部手術
• 行為上的健康問題。心理或精神問題（恐慌攻擊，害怕封閉或是開放場所）
• 癲癇、發病、抽搐或服用預防這類疾病的藥物？
• 復發性偏頭痛或服用預防藥物？
• 眼前發黑或昏厥（完全／部份失去反應）？
• 您是否常常暈船、暈車、暈機等？
• 需要醫療的腹瀉或脫水
• 潛水意外或減壓病？
• 有復發性背部疾病的病史？
• 無法從事溫和的運動（在 12 分鐘以內步行 1.6 公里／ 1英里）
• 在過去五年內有因喪失意識而頭部受傷﹖
• 經常性背部毛病？
• 糖尿病？
• 因手術、受傷或骨折所導致的背部、手臂或腳部問題﹖
• 高血壓或服藥控制血壓
• 心臟病？
• 心臟病發病？
• 心絞痛或心臟手術或血管手術？
• 靜脈竇手術？
• 耳朵疾病、聽力喪失或平衡問題？
• 在飛機或高山旅遊時平衡耳朵的問題？
• 經常性耳朵問題？
• 失血或其他血液疾病的病歷？
• 疝氣？
• 潰瘍病歷或潰瘍手術？
• 結腸造口術（人工肛門）？
• 在過去五年內有濫用藥物或酒精？

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)?