Night Course + Medical Form

Course start date

Group name (If relevant)

Eg, School, Scout group, trip, club you are booking with

Please provide your Diver number and agency

Number of Dives

Date of last dive

Please let us know the month/year if you dont know exactly

Name

First

Last

Date of Birth

Email

Phone number

Emergency Contact Name

(Not someone who is in the water with you)

Emergency Contact Number

(Not someone who is in the water with you)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

I have my own:

BCD
REGULATORS
FINS
NONE

If you need to hire kit not listed please get in touch with us.

Chest Size (cm)

Full loop around widest part of the chest

Height (cm)

Foot Size (UK)

Divecrew Cancellation Policy and Procedures 2025

I confirm I have read & understand.

https://divecrew.dive360.biz/divecrew-policy-and-procedures-2025

Divecrew Participation Disclaimer, Non-Agency Disclosure & Risk Acknowledgment 2025

I confirm I have read & understand.

https://divecrew.dive360.biz/divecrew-participation-disclaimer-non-agency-disclosure-risk-acknowledgment-2025-

Divecrew Additional Terms and Conditions for Diving Activities 2025

I confirm I have read & understand.

https://divecrew.dive360.biz/divecrew-additional-terms-and-conditions-for-diving-activities-20251

GDPR Agreement

I consent to having this website and company store my submitted information so they can respond to my inquiry and file my data.

Medical Form

I have a medical form signed off by a doctor in the past year

Yes
No

Please upload medical sign off here:

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

1. Have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19.

Yes (Fill in Box A also)
No

2. I am over 45 years of age

Yes (Fill in Box B also)
No

3. I struggle to perform moderate exercise.

Yes
No

(for example, walk 1.6 kilometers/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

4. I have had problems with my eyes, ears, or nasal passages/sinuses.

Yes (Fill in Box C also)
No

5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

Yes
No

6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.

Yes (Fill in Box D also)
No

7. I am currently undergoing treatment (or have required treatment within the last five years)

Yes (Fill in Box E also)
No

for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.

8. I have had back problems, hernia, ulcers, or diabetes.

Yes (Fill in Box F also)
No

9. I have had stomach or intestine problems, including recent diarrhea.

Yes (Fill in Box G also)
No

10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).

Yes
No

3. Please provide details:

5. Please provide details

10. Please provide details

If you answered NO to all 10 questions above,

A - Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).

Yes
No

A - Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.

Yes
No

A - A problem or illness involving my heart

Yes
No

such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.

A - Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.

Yes
No

A - A diagnosis of COVID-19 that required medical treatment in hospital as a result of this. For example resulting in being on a ventilator

Yes
No

A -Please provide details:

B - I currently smoke or inhale nicotine by other means.

Yes
No

B - I have a high cholesterol level.

Yes
No

B - I have high blood pressure.

Yes
No

B - I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50.

Yes
No

(including abnormal heart rhythms, coronary artery disease or cardiomyopathy)

B -Please provide details:

C - I have had sinus surgery within the last 6 months.

Yes
No

C - I have had ear disease or ear surgery, hearing loss, or problems with balance.

Yes
No

C - I have had recurrent sinusitis within the past 12 months.

Yes
No

C - I have had eye surgery within the past 3 months.

Yes
No

Please provide details:

D - I have/have had head injury with loss of consciousness within the past 5 years.

Yes
No

D - I have/have had persistent neurologic injury or disease.

Yes
No

D - I have/have had recurring migraine headaches within the past 12 months, or take medications to prevent them.

Yes
No

D - I have/have had blackouts or fainting (full/partial loss of consciousness) within the last 5 years.

Yes
No

D - I have/have had epilepsy, seizures, or convulsions, OR take medications to prevent them.

Yes
No

Please provide details:

E - I have/have had behavioral health, mental or psychological problems requiring medical/psychiatric treatment.

Yes
No

E - I have/have had major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.

Yes
No

E - I have/have had been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care.

Yes
No

E - I have/have had an addiction to drugs or alcohol requiring treatment within the last 5 years.

Yes
No

Please provide details:

F - I have had recurrent back problems in the last 6 months that limit my everyday activity.

Yes
No

F - I have had back or spinal surgery within the last 12 months.

Yes
No

F - I have had diabetes, either insulin- or diet-controlled, OR gestational diabetes within the last 12 months.

Yes
No

F - I have had an uncorrected hernia that limits my physical abilities.

Yes
No

F - I have had active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.

Yes
No

Please provide details:

G - I have had ostomy surgery and do not have medical clearance to swim or engage in physical activity.

Yes
No

G - I have had dehydration requiring medical intervention within the last 7 days.

Yes
No

G - I have had active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.

Yes
No

G - I have had frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).

Yes
No

G - I have had active or uncontrolled ulcerative colitis or Crohn’s disease.

Yes
No

G - I have had bariatric surgery within the last 12 months.

Yes
No

or had problem

Please provide details:

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.

Date today

If you answered YES to questions 3, 5 or 10 above OR to any of the questions in boxes from A-G,

Please read and agree to the statement above by signing and dating it, call us directly to discuss. If required: these will be the pages to take with you to your physician for a medical evaluation.(Participant Questionnaire and you will also need the Physician’s Evaluation Form). Please call us directly first if unsure. Participation in a diving course may require your physician’s approval.

Signature

Clear Signature

Mon - Sat	09:00 - 18:00
Sun	09:00 - 17:00

Medical Form

Divecrew – Head Office

BSAC – Aldershot Dolphins

Head Office – Open Hours