“For the Love of Nature: No Pepper, Please! Fill Out the Online Form Please read carefully and fill in all blanks before signing.Nombre *Apellido *Date Of Birth *Phone *Correo Electrónico *Select *Choose if you are certified or notI am a certified diverI am not a certified diverStreet Address *Country *AfganistánAlbaniaArgeliaSamoa AmericanaAndorraAngolaAnguilaAntártidaAntigua y BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaiyánBahamasBahreinBangladeshBarbadosBielorrusiaBélgicaBeliceBeninLas BermudasButánBoliviaBosnia y HerzegovinaBotsuanaIsla BouvetBrasilTerritorio Británico del Océano ÍndicoBruneiBulgariaBurkina FasoBurundiCamboyaCamerúnCanadáCabo VerdeIslas CaimánRepública CentroafricanaChadChileChina, República Popular deIsla de NavidadIslas CocosColombiaComorasCongo, República Democrática delCongo, República delIslas CookCosta RicaCosta de MarfilCroaciaCubaCurazaoChipreRepública ChecaDinamarcaYibutiDominicaRepública DominicanaTimor OrientalEcuadorEgiptoEl SalvadorGuinea EcuatorialEritreaEstoniaEtiopíaIslas MalvinasIslas FeroeFiyiFinlandiaFranciaFrancia MetropolitanaGuayana FrancesaPolinesia FrancesaTerritorios Australes FrancesesGabónGambiaGeorgiaAlemaniaGuernseyGhanaGibraltarGreciaGroenlandiaGranadaGuadalupeGuamGuatemalaGuineaGuinea-BissauGuayanaHaitíIslas Heard y McDonaldHondurasHong KongHungríaIslandiaIndiaIndonesiaIránIrakIrlandaIsraelItaliaJamaicaJapónJerseyAtolón JohnstonJordaniaKazajstánKeniaKiribatiCorea del NorteCorea del SurKosovoKuwaitKirguistánRepública Democrática Popular LaoLetoniaLíbanoLesotoLiberiaLibiaLiechtensteinLituaniaLuxemburgoMacaoMacedonia NorteMadagascarMalawiMalasiaMaldivasMaliMaltaIslas MarshallMartinicaMauritaniaMauricioMayotteMéxicoMicronesiaMoldaviaMónacoMongoliaMontserratMontenegroMarruecosMozambiqueBirmaniaNamibiaNauruNepalPaíses BajosAntillas NeerlandesasNueva CaledoniaNueva ZelandaNicaraguaNigeriaNigeriaNiueIsla NorfolkIslas Mariana del NorteNoruegaOmánPakistánPalaosPalestina, Estado dePanamáNueva GuineaParaguayPerúFilipinasIslas PitcairnPoloniaPortugalPuerto RicoKatarIsla ReuniónRumaniaRusiaRuandaSan Cristóbal y NievesSanta LucíaSan Vicente y las GranadinasSamoaSanta ElenaSan Pedro y MiquelónSan MarinoSanto Tomé y PríncipeArabia SauditaSenegalSerbiaSeychellesSierra LeonaSingapurSan MartínEslovaquiaEsloveniaIslas SalomónSomaliaSudáfricaIslas Georgias del Sur y Sandwich del SurEspañaSri LankaPersonas ApátridasSudánSudán, surSurinamSvalbard y Jan MayenSuazilandiaSueciaSuizaSiriaTaiwán, República de ChinaTayikistánTanzaniaTailandiaTogoTokelauTongaTrinidad y TobagoTúnezTurquíaTurkmenistánIslas Turcas y CaicosTuvaluUgandaUcraniaEmiratos Árabes UnidosReino UnidoIslas Ultramarinas Menores de Estados UnidosEstados UnidosUruguayUzbekistánVanuatuCiudad del VaticanoVenezuelaVietnamIslas Vírgenes BritánicasIslas Vírgenes de los Estados UnidosIslas Wallis y Futuna Sahara OccidentalYemenZambiaZimbabueNombre *Apellido *Phone *Correo Electrónico *RELEASE OF LIABILITY AGREEMENTAcknowledgment of Risks By signing this form, I acknowledge that scuba diving and related activities involve inherent risks, including but not limited to: Decompression sickness Air expansion injuries Drowning Boat-related accidents Other sea-related hazards I understand and accept these risks, and I choose to participate voluntarily. Release of Liability I hereby release Ankla Azul Diving Center, its instructors, staff, and affiliates from any liability for personal injury, property damage, or wrongful death arising from my participation in diving activities, regardless of cause. Equipment Responsibility I agree to: Inspect all provided equipment before use. Return equipment in good condition or cover the cost of loss or damage. Health Declaration I certify that I am in good physical and mental health for diving and not under the influence of drugs or alcohol. If I have medical conditions, I have consulted a physician and obtained clearance to dive. Personal Belongings Ankla Azul is not responsible for loss or damage to personal belongings brought to the activity. Accessibility and Privacy Notice This form complies with accessibility standards. If you have questions or require assistance, contact us. Your personal information is securely stored and used solely for participation purposes.Yes, I declare *Through this document, I declare that I am a certified diver or a diving student under the control and supervision of a certified diving professional. I affirm that I understand that diving is considered a high-risk activity and its inherent hazards may result in serious injuries or death. Additionally, I understand and accept the risks associated with the motorboat trip to and from the dive site. I understand that these dangers include, but are not limited to, air expansion injuries, drowning, decompression sickness, slips or falls on the boat, cuts or injuries from another boat while I am in the water, injuries occurring while boarding or disembarking, and other sea-related risks. By signing this release of liability agreement, I certify that I am aware of and expressly assume the risks involved in conducting such dives, whether they are recreational dives or part of a diving course.I acknowledge *Acknowledgment of Risks By signing this form, I acknowledge that scuba diving and related activities involve inherent risks, including but not limited to: Decompression sickness Air expansion injuries Drowning Boat-related accidents Other sea-related hazards I understand and accept these risks *I understand and accept these risks, and I choose to participate voluntarily. Release of Liability I hereby release Ankla Azul Diving Center, its instructors, staff, and affiliates from any liability for personal injury, property damage, or wrongful death arising from my participation in diving activities, regardless of cause.I understand and accept these risks *I understand and accept these risks, and I choose to participate voluntarily. Release of Liability I hereby release Ankla Azul Diving Center, its instructors, staff, and affiliates from any liability for personal injury, property damage, or wrongful death arising from my participation in diving activities, regardless of cause.I accept *Personal Belongings Ankla Azul is not responsible for loss or damage to personal belongings brought to the activity.I agree *Equipment Responsibility I agree to: Inspect all provided equipment before use. Return equipment in good condition or cover the cost of loss or damage. I certify *Health Declaration I certify that I am in good physical and mental health for diving and not under the influence of drugs or alcohol. If I have medical conditions, I have consulted a physician and obtained clearance to dive.Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to “diving” on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. *SíNoI am over 45 years of age. *SíNoI struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months. *SíNoI have had problems with my eyes, ears, or nasal passages/sinuses *SíNoI have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. *SíNoI have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. *SíNoI am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability *SíNohave had back problems, hernia, ulcers, or diabetes. *SíNoI have had stomach or intestine problems, including recent diarrhea *SíNoI am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam). *SíNoConsentimiento *Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.Signature *Start signing your signature hereYour browser does not support e-Signature field.Enviar mensajePor favor, no rellenes este campo.
