Release and Indemnity Agreement
The undersigned being the parents, guardians or persons having the care and custody of the student/participant in an "I Tried Scuba" event ,
do hereby consent that __________________________________________ may take instruction, in skin or SCUBA diving and/or participate in the diving activities and instruction for skin and/or SCUBA diving at the DURLAND SCOUT CENTER, Rye, New York.
I,________________________________, being the parent(s) or legal guardian(s) of the student, have been advised and thoroughly informed of the inherent dangers of skin or SCUBA diving, including but limited to (a) the loss of life from drowning, (b) loss of hearing, and (c) possible permanent damage to the ears, nose, throat and pulmonary or central nervous systems.
* In consideration of the above individual being accepted for participation in the program we (I) contract and agree that the BOY SCOUTS OF AMERICA, INC. and the DURLAND SCUBA COMMITTEE/VENTURE CREW 53, of the BOY SCOUTS OF AMERICA, and their agents, servants and employees, will not be held liable for any occurrence in connection with this diving class which may result in injury, death, loss or damage to this individual or his property and hereby release, remise and forever discharge each of the aforesaid from any and all claims or causes of action which may hereafter arise or occur.
I hereby personally assume all risks in connection which said course for any harm, injury, loss or damage including death which may be fall him or his property while enrolled as a student of the course, including all risks connected therewith, whether direct or indirect whether foreseen or unforeseen, and we further agree to indemnify, save and hold harmless said program and the aforesaid organizations and persons from any claim by me or my enrollment or participation in this course or program.
It is clearly understood and agreed that any and all possible present or future claims or causes of action and all rights in connection therewith are waived at this time, prior to participation in the course, as a part of the consideration of being allowed to proceed with the course at the rate charged.
*I have fully informed
myself of the contents of this affirmation and release, waiver and indemnity
agreement by reading it before I signed it. I represent that
________ years of age
and was born on ___________.
(1) Signature of Parent/Guardian_____________________________________________
(2) *Signature of Student
Date___________________ Witness to Signature_________________
Youth Participants - complete entire form.
- complete lower portion only (*).
COPY THIS PAGE FOR ALL PARTICIPANTS
DURLAND SCUBA STATEMENT CONCERNING THE MEDICAL CONSTRAINTS FOR THE “I TRIED SCUBA” AND SCUBA CERTIFICATION PROGRAMS
Durland Scout Center has enjoyed an enviable safely record since its inception, especially in our scuba programs. We believe that our mission is to provide a safe and enjoyable aquatic experience for those youth that attend our facility.
With this in mind, we would like to remind every Scuba participant of the seriousness with which we will adhere to the medical constraints listed below, as published by the Recreational Scuba Training Council.
The following conditions are considered to be ABSOLUTE disqualification. If you have one of the following medical conditions, you will not be permitted to dive in any Durland program.
1. Congestive Heart Failure or Heart Disease
2. History of Seizure Disorder or Head Injury
3. Prior history of DCS (decompression sickness) within the past 6 months
4. Sickle Cell Disease or Trait
6. History of Inner Ear Surgery
7. Inability to Equalize Pressure in the Middle Ear by Auto-inflation
The following conditions require evaluation by a "Diving Doctor" (Hyperbaric Physician). To find a "Diving Doctor" near you, you or your physician should contact the Diver's Alert Network at Duke University. Their telephone number is 919-684-2948.
2. History of Asthma or Exercise Induced Bronchospasm
3. Migraine Headaches
4. Extreme Obesity
5. History of Spinal Cord or Brain Injury
9. Perforation of Tympanic Membrane
10. History of Pulmonary Overpressure Accident in Previous Diving
11. Inguinal Hernia
12. Insulin Dependent Diabetes Mellitus
In the interest
of safety, the Durland Scuba Program reserves the right to refuse participation
in the Scuba programs to anyone who has the aforementioned medical problems.
Even certified divers must realize that with the changes in diving medicine
it is necessary to keep abreast of their medical status. We will refer
to hyperbaric physicians in order to make a decision if diving eligibility
is in question.