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ΑΚΤΗ ΨΑΡΟΝΤΟΥΦΕΚΟ ΣΚΑΦΟΣ ΓΛΥΚΑ ΝΕΡΑ ΔΙΑΦΟΡΑ ΘΕΜΑΤΑ

A.I.D.A CYPRUS - ΕΝΤΥΠΑ ΣΥΜΜΕΤΟΧΗΣ ΑΓΩΝΑ ΣΤΑΤΙΚΗΣ-ΔΥΝΑΜΙΚΗΣ

A.I.D.A CYPRUS - ΕΝΤΥΠΑ ΣΥΜΜΕΤΟΧΗΣ ΑΓΩΝΑ ΣΤΑΤΙΚΗΣ-ΔΥΝΑΜΙΚΗΣ

Δημοσίευσηαπό freediver33 » Τετ Απρ 22, 2009 9:52 am

AIDA
CYPRUS
APNEA SPRING GAMES 2009


Name:__________________________________________________________ Date of Birth:_______________________

**IMPORTANT – PLEASE READ ** Freediving is a strenuous activity carried out in the underwater environment, which may, under certain conditions, increase your risk of injury. This risk may be significantly increased if you have certain physical conditions. These same physical conditions would not necessarily be a safely factor in other strenuous activities or sports. AIDA Cyprus has, therefore, developed the following questionnaire to make you aware of these conditions. Failure to address these conditions prior to engaging in breath-hold diving activity may endanger your health, the safety of any person you may dive with in the future.

MEDICAL QUESTIONNAIRE
Please read each question carefully and answer them accurately. Please explain any “yes” answers in the space provided at the bottom of this questionnaire. This form and your answers will be kept confidential. A positive answer will not necessarily exclude you from participating in any endorsed events/competitions.

1. NEUROLOGICAL CONDITIONS: Especially any history of seizure disorder, stroke, brain surgery, black out, severe migraine headaches, or aneurysm of the brain’s blood vessels. ___ YES ___ NO

2. CARDIOVASCULAR CONDITIONS: Especially heart attack, heart surgery, irregular heart beat, uncontrolled elevated blood pressure (hypertension).
___ YES ___ NO

3. PULMONARY CONDITIONS: Especially a history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, severe damage to lung tissue, emphysema, or any lung problem which interferes with your ability to breathe. ___ YES ___ NO

4. EAR CONDITIONS: Permanent holes of the eardrums, history of ruptured eardrum, permanent tubes in eardrums, severely impaired hearing or hearing loss in one or both ears, or major ear surgery.
___ YES ___ NO

5. SINUS CONDITIONS: Tumor, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, or persistent sinus infection. ___ YES ___ NO

6. ASTHMA: History of asthma or asthma attacks. Any history of wheezing caused by exercise, anxiety, cold, fatigue, etc. Any condition requiring medication and/or use of an inhaler for control of wheezing. ___ YES ___ NO

7. DIABETES MELLITUS: Especially Type I Diabetes (Insulin dependent) or Type II Diabetes, which requires insulin or oral medication for control. Any form of Diabetes that is unstable, “brittle” or produces episodes of hypoglycemia (low blood sugar reactions), hyperglycemia (extremely high blood sugar with ketosis) or if there is related kidney disease, eye disease, heart disease or blood vessel disease. Also, of history of elevated blood sugar during pregnancy.
___ YES ___ NO

8. PREGNANCY: If you are presently pregnant or planning to be pregnant. ___ YES ___ NO

9. FREEDIVING/SCUBA DIVING CONDITIONS: Previous history of a diving accident, decompression sickness, decompression of the inner ear of air embolus.
___ YES ___ NO

10. MEDICATION: Any medication taken on a regular basis either over-the-counter or prescribed by a physician. ___ YES ___ NO

11. GENERAL MEDICAL PROBLEMS: Any physical and/or emotional condition not mentioned that might effect your safety in an underwater environment or affect your judgment under times of physical or emotional stress.
___ YES ___ NO

I certify that I have answered the above questions accurately and honestly.

Signed:______________________________________________________________ Date:___________________________

Witness:_____________________________________________________________ Date: ___________________________

________ Approved for Application

________ Requires Medical Clearance

..........................................................................................................................................................................................

AIDA
CYPRUS
APNEA SPRING GAMES 2009
1ST OF MAY, 2009
LARNACA


READ CAREFULLY

Please read this document carefully because signing it indicates you are waiving certain legal rights. If you have any questions, ask any member of the support staff, or an attorney, before initialing a paragraph to signify your understanding. Print when filling in the blanks and initial each paragraph before signing your name at the end of this waiver. ________________________________________________________________________


I, _________________________________________________ (Print name clearly) hereby affirm that I have been thoroughly informed of the risk involved with any free diving/breath-hold diving activity.

____ I understand that free diving/breath-holding underwater may involve inherent risks, including but not limited to hypoxia, marine life injuries, barotrauma, shallow water blackout, drowning or hyperbaric accidents. Treatment of a free diving/breath-hold diving accident victim with these or other injuries may require immediate medical attention and/or hyperbaric oxygen therapy. I understand that the training dives for this free dive/breath-hold dive may be at a location that is remote, either by time, distance or both, from a hospital and/or a recompression chamber. I still choose to proceed with my free dive/breath-hold dive in spite of the increased risk to me because a hospital or recompression chamber is not close by in the event I am injured.

____ I specifically understand that the risk of shallow water blackout is inherent to free diving/breath hold diving activities, and that I still intend to participate in free diving/breath-hold diving. I agree that I will not free dive/breath-hold dive alone; I will always free dive with a qualified surface support free diver with me at all times.

____ I understand and agree that neither “AIDA CYPRUS”, its Directors, employees, volunteers, nor the sponsors of the event, nor any of their respective officers, agents and employees or volunteers (hereinafter referred to as "Released Parties") may be held liable or responsible in any way for any injury, death, or other damages to myself, my family, heirs or assigns that may occur as a result of my participation in this free dive/breath-hold dive or as a result of the negligence of any party, including the Released Parties, whether passive or active.


____In consideration of being allowed to participate in this free dive/breath-hold dive training/competition, I hereby personally assume all risks in connection with it, for any harm,
injury, or damage that may befall me while I am participating in this free dive/breath-hold dive, including all risks connected therewith, whether foreseen or unforeseen.


____ I agree to hold harmless the Released Parties from any claim or lawsuit by myself, my family, estate, heirs or assigns, arising out of my participation in this free dive/breath-hold dive, including any and all claims arising during my practicing and any arising during or after I complete the free dive/breath-hold dives.

____ I understand that any diving activities are physically strenuous and that I will be exerting myself during this free dive/breath-hold dive, and I expressly assume the risk of any and all injuries, and I will not hold the Released parties responsible if I am injured as a result of heart attack, panic, hypoxia, hyperventilation, oxygen toxicity, decompression illness, gas embolism, drowning or any other cause of injury or death not specifically stated herein.

____ I release and grant full and unencumbered rights to the released parties the use of my filmed/videotaped/recorded image including any edited, revised or modified versions thereof, as well as my name, voice and/or likeness, for purposes of promotion, advertising, training materials and trade in any and all media anywhere in the world at any time without limitation.

____ I am aware of the prerequisite skill level and/or equivalent diving experience necessary to participate in this free dive/breath-hold dive, and I stipulate that I meet these requirements.

____ I understand that I am responsible for supplying my free diver/breath-hold diving equipment in proper operating condition, regardless of where I obtained it or from whom.

____ I understand that all the terms herein are contractual, they are not a mere recital, and my signing this document is done of my own free act and in so doing, I waive my legal rights to sue.

____ I state that I am of lawful age and legally competent to sign this liability release, or that I have the written consent of my parent or legal guardian to engage in this free dive/breath-hold dive under the conditions of this waiver as stipulated by their signature below. It is the intention of ___________________________________________ (print name) by this written document to exempt and release all of the Released Parties as defined herein, from all liability whatsoever for personal injury, property damage or wrongful death however caused, including but not limited to the negligence of the Released parties, whether passive or active.


____ I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF RISK BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF AND MY HEIRS.

Signature:________________________________________________ Date:__________

Signature of Parent or Guardian (if under 18 years of age):_________ Date:__________

Address: ________________________________________________________________

Phone:______________________________

Witness:_________________________________________________ Date:__________

...........................................................................................................................................................................................


AIDA
CYPRUS

APNEA SPRING GAMES 2009
1η Μαίου, 2009


Όνομα:____________________________________________________

Ημερομηνία Γεννήσεως:_____________________________________

Διεύθυνση:_________________________________________________

E-mail:____________________________________________________

Tηλ:______________________________________________________

Θα ήθελα να συμμετάσχω στον αγώνα στις ακόλουθες κατηγορίες:



Στατική Άπνοια (STA) Αναμενόμενος χρόνος:________ λεπτά


Δυναμική Άπνοια με Πέδιλα (DYN) Απόσταση:_____________ μέτρα


Δυναμική Άπνοια χωρίς Πέδιλα (DNF) Απόσταση:_____________ μέτρα




Υπογραφή:____________________________________ Ημερομηνία:____________
You go down to the bottom of the sea where the water is not eaven blue any more and the sky is only a memory, a thought in the silence!!!
freediver33
 
Δημοσ.: 165
Εγγραφη: Τρί Νοέμ 27, 2007 6:37 pm

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