Merak Diving | Diver Registration

DNI, NIE, CIF,Passport*

Name and surname*
*

Birth date*

Age*

Telephone*
*

Email*
*

Address (opctional)

Postal code (opctional)

Town (opctional)

Country (opctional)

Province (opctional)

Language

Are you going to do an Dive or Try a dive?.

Make sure if your departure is from Mahón or Fornells.

Try to arrive at the time we quote you, neither before nor after, as this will prevent you from getting there. We will all wait less.

Dive Try scuba diving Open Water Course

Diver certification*

Certifying agency*

Certification ID

Number of dives*

Date of the last dive?*

Do you need insurance?*
Days from the date of contracting the insurance.

Insurance carrier*

Expiration Insurance*

Do you need diving equipment? (opctional)

Tell us what you need, the size, the foot number ...
If you do not know the size, you can tell us your height (cm), how much you weigh (kg), and what foot size you have.
This information helps us to have everything ready for when you come.

*Divers are obliged (by regulations) to dive with a computer. This is for security. If you don't have your own, you can rent it at Merak Diving.
Also, we must carry a decorative buoy on our vest, at least one per couple.

Respect the rental material!

Image of the degree (opctional)

Contact and Telephone Emergencies.*

Take the Medical surveyI have a Medical Certificate

Attach Medical Certificate

Diver Medical | Participant Questionnaire

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.

Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.

Note to women: If you are pregnant, or attempting to become pregnant, do not dive.

	Answer all questions YES or NO
1	I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance.	YES	NO
	Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease.	YES	NO
	Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.	YES	NO
	A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.	YES	NO
	Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.	YES	NO
	Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.	YES	NO
2	I am over 45 years of age.	YES	NO
	I currently smoke or inhale nicotine by other means.	YES	NO
	I have a high cholesterol level.	YES	NO
	I have high blood pressure.	YES	NO
	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 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).	YES	NO
3	I 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.	YES*	NO
4	I have had problems with my eyes, ears, or nasal passages/sinuses.	YES	NO
	Sinus surgery within the last 6 months.	YES	NO
	Ear disease or ear surgery, hearing loss, or problems with balance.	YES	NO
	Recurrent sinusitis within the past 12 months.	YES	NO
	Eye surgery within the past 3 months.	YES	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	NO
	Head injury with loss of consciousness within the past 5 years.	YES	NO
	Persistent neurologic injury or disease.	YES	NO
	Recurring migraine headaches within the past 12 months, or take medications to prevent them.	YES	NO
	Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.	YES	NO
	Epilepsy, seizures, or convulsions, OR take medications to prevent them.	YES	NO
7	I 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 or developmental disability.	YES	NO
	Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.	YES	NO
	Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.	YES	NO
	Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.	YES	NO
	An addiction to drugs or alcohol requiring treatment within the last 5 years.	YES	NO
8	I have had back problems, hernia, ulcers, or diabetes.	YES	NO
	Recurrent back problems in the last 6 months that limit my everyday activity.	YES	NO
	Back or spinal surgery within the last 12 months.	YES	NO
	Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.	YES	NO
	An uncorrected hernia that limits my physical abilities.	YES	NO
	Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.	YES	NO
9	I have had stomach or intestine problems, including recent diarrhea.	YES	NO
	Ostomy surgery and do not have medical clearance to swim or engage in physical activity.	YES	NO
	Dehydration requiring medical intervention within the last 7 days.	YES	NO
	Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.	YES	NO
	Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).	YES	NO
	Active or uncontrolled ulcerative colitis or Crohn�s disease.	YES	NO
	Bariatric surgery within the last 12 months.	YES	NO
10	I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).	YES*	NO

Fecha de la versión: 01-02-2022 SSI

If you answered NO to the 10 previous questions, is not required a medical evaluation. Please, read and accept the following participant statement with the date and your signature.

Participant statement: I answered all the questions honestly and I understand that I accept the responsibility for any consequence resulting from any question that I could have answered inaccurately or any current or past health condition that I didn’t reveal.

Signature of the participant (or if the person is a minor, it’s required the signature of the participant’s parent/guardian).

Name of parent/guardian in case of minor

Open Sign Pad

Sign

Date 21/11/2024

Instructor: Xavier Boqué Arguemí. Dive Center: Merak Diving

* If you answered YES to the previous questions 3, 5 or 10 or any of the questions of the page 2, read and accept the previous statement with the date and signature and bring the Medical Evaluation form to your doctor for a medical evaluation. The participation in a diving program requires the evaluation and approval of your doctor.

I accept the conditions
I accept the Privacy Policy

ACCEPTANCE AND CONSENT TREATMENT OF IMAGESO

The right to one's own image is recognized by article 18 of the constitution and regulated by Law 1/1982, of May 5, on the right to honor and self-image, Law 15/1999, of December 13, on Protection of Personal Data.Merak Yacht Charter S.L. asks for consent to be able to publish the images in which they appear individually or in groups, taken at school or during practices.

I consent

I don't consent

The User declares to have been informed of the conditions on protection of personal data, accepting and consenting to the automated treatment thereof by MERAK CHARTER S.L in the manner and for the purposes indicated in this Personal Data Protection Policy.Through this Privacy Policy we inform you that the photographs that are posted on the web or on the social networks of Merak Diving, Merak Charter or Merak Escuela N�utica are the property of MERAK CHARTER SL, including those of minors, in which, To obtain these, the prior consent of the parents, guardians or legal representatives has been obtained by accepting this form. However, the parents, guardians or representatives of the minors, as holders of the exercise of their rights, and always after a formal written request, may indicate the refusal to use the image of the minor; in this case, the image will appear pixelated or it will not be published.