Read this statement prior to signing it. You must complete this additional medical questionnaire to enrol in a diver training program or to participate in any diving activity. If you are a minor, you must have this statement signed by your parent or guardian.
The purpose of this medical questionnaire is to ensure that you are medically fit to dive. Please answer the following questions with a YES or NO. If you are not sure, answer YES. A positive response means that there may be a preexisting condition that could affect your safety while diving. If any of these items apply to you, we must request that you consult with a physician, preferably a specialist in diving medicine, prior to participating in diving activities.
Within the 40 days immediately preceding the date of this Health Declaration Form, have you:
The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for any omissions in disclosing my existing or past health conditions. I also commit to inform Sea Spirit S.S.D. A.R.L about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.
I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by Sea Spirit S.S.D. A R.L, and will take all reasonable preventive steps that may be recommended by Sea Spirit S.S.D. A R.L, or any relevant public authority.*
I WILL accept and observe all instructions by Sea Spirit S.S.D. A R.L intended to abide by all existing regulations, required to help prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities*
I ACKNOWLEDGE and ACCEPT that this declaration will be considered as my consent to Sea Spirit S.S.D. A R.L o retain this declaration and disclose it to any relevant authority or service provider for the purposes of ensuring the safety of any third parties that may come in contact with me prior to, during, and after any diving activity.*
DECLARES to be aware that the structure within which it performs sporting practice is constituted legally in the form of non-profit sports club with limited liability and is recognized by CONI.
DECLARES also to have accepted the insurance policy for personal injuries provided by the affiliation of the company to protect its practitioners in the performance of institutional activities. The affiliated then declares to relieve the company itself of any compensation, even partial, not recognized or partially reimbursed by the insurance company concerned, for accidents and injuries that may occur before, during and after the activities. Declares to have understood the information on the use of personal data, pursuant to Article 13 of Legislative Decree No. 196 of June 30, 2003, containing the new code regarding the protection of personal data. It allows their treatment to the extent necessary for the pursuit of statutory and institutional purposes. Pursuant to article 13 of the
legislative decree n ° 196/2003, containing provisions on the new code regarding the protection of personal data, declares to be aware that the data provided will be processed in compliance with the aforementioned law and the confidentiality obligations, which will be treated only for institutional activities, therefore, strictly connected to the statutory activities and that the treatment will take place through the use of electronic or paper support, suitable to guarantee the security and confidentiality of the same. In relation to the aforementioned treatments, which may exercise the rights referred to in art. 7 of the d. lgs. N ° 196/2003 (cancellation, modification, opposition to treatment).
I hereby assign all rights to the film, digital media, photography, sound recording and printed quotes thereof made of me during my participation in the Sea Spirit daily program by representatives of Sea Spirit SSD ARL, or their designee. I hereby authorize the reproduction, copyright, exhibition, and/or distribution of said materials worldwide without limitation for any purpose. Sea Spirit SSD ARL, or their designee, may use above mentioned materials for purposes of advertising, publicity and sales promotion. No money shall be due me for such use, now or in the future
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