QUASAR NAUTICA DIVE QUESTIONAIRE
|Name of Yacht:||Sailing Date:|
|Date of Birth:||Passport #:|
|Do you have Diving Insurance? __Yes __No If YES, what type?|
|SCUBA CERTIFICATION AGENCY:|
|CERTIFICATION #:||DATE OF CERTIFICATION:|
|How do you rate yourself as a diver? Beginner Intermediate Advanced Expert|
|Number of open water dives since certified? ______|
|Number of open water dives during last year? ________|
|Date and Place of last open water dive:|
|How do you rate your health in general?|
|Have you had decompression sickness, bends or other diving accidents?|
|Do you have asthma or emphysema?|
|Have you ever suffered from any mental problems?|
|Are you currently on a special diet?|
NOTE: On board you will be asked to fill out a more detailed medical questionnaire.
IMPORANT: In case of medical emergency, I authorize the captain and/or crew of the vessel to administer first aid or get proper medical attention if necessary. I understand that the nearest operational decompression chamber is many hours away and requires air evacuation. The time involved in boat and air transport poses additional risks to my personal safety. I voluntarily accept this additional risk and I am fully prepared to pay all expenses related to transportation, decompression chamber treatment, medical and all other expenses incurred on behalf of myself and/or family that will accompany me.
NOTE: Unforseen circumstances can and do happen, therefore Quasar Nautica strongly recommends that purchase of trip cancellation insurance, as well as accidental, medical and luggage insurance.
Have you purchased trip cancellation insurance? YES
By checking "NO" you are agreeing to the terms of the Booking and Cancellation policy of Quasar Nautica, Galapagos Expeditions.
Having read the above and signed the Dive Waiver and Release of Liability Form given to my by Quasar Nautica, I declare all of the information I have recorded above is correct.