Name of Yacht: Sailing Date:
Date of Birth: Passport #:
Do you have Diving Insurance? __Yes __No        If YES, what type?
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.
1: I confirm that I am aware that diving in the Galapagos is for experienced divers only.
2: I confirm that I am aware that diving in the Galapagos takes place in cold water with strong currents and surges.
3: I confirm that the dive master on board is there to guide my diving but not to care for me personally.
4: I confirm that Imust always remain with my "buddy" while diving in the Galapagos.
5: I confirm that I will obey the instructions of the dive master on my cruise and understand that his/her assessment of my diving ability will be final and binding and he/she may exclude me from certain dives.
6: I confirm that I understand the the remoteness of the area, weather conditions, operational difficulties may result in the substitution of the faculties and/or equipment as well as minor inconveniences or modification to the diving portions of the agreed dive itinerary.

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      NO
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.