Freediving in Lombok

Student Registration

Freedive Lombok  ·  Complete all three sections before your course

1
Registration
2
Medical
3
Waiver

Registration

Personal details and course information

Personal information
Full name is required
Valid email required
WhatsApp number required
Country is required
Required
Required
Course details
Insurance
Active insurance is mandatory for all training and courses with Freedive Lombok. Diving and/or travel insurance is required.
Please confirm your insurance status
Consent

I give consent to the use of photos and videos taken during training for private use and promotional materials / social media. You may withdraw consent at any time.

Medical questionnaire

The purpose of this questionnaire is to determine if you should be examined by your doctor before participating in freediving activities. A positive (i.e. “YES”) response to a question does not necessarily disqualify you from freediving, but means that there is a pre-existing condition that may affect your safety while freediving, and you MUST seek the advice of a physician prior to engaging in freediving activities. The physician must sign at the bottom of the form to state that they find no medical conditions incompatible with freediving if any “YES” box is ticked. Please answer the following questions about your past and present medical history by ticking the box marked YES or NO. If you are not sure, answer YES. Do you currently or have you previously suffered from these medical conditions?
Medical history
Neurological conditions
Especially any history of seizure disorder, stroke, brain surgery, repeated blackouts or fainting fits, severe migraine headaches or aneurysm of the brain blood vessels.
Your instructor will follow up with you about this.
Cardiovascular conditions
Especially heart attack, heart surgery, irregular heartbeat, uncontrolled elevated blood pressure.
Your instructor will follow up with you about this.
Pulmonary conditions
Especially a history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, severe damage to lung tissue, emphysema, or any lung problem which interferes with your ability to breathe.
Your instructor will follow up with you about this.
Ear conditions
Permanent holes of the eardrums, history of ruptured eardrum, permanent tubes in eardrums or major ear surgery.
Your instructor will follow up with you about this.
Sinus conditions
Tumor, polyps, or cyst of the sinus cavities or nasal passages, major sinus surgery, or sinus infection.
Your instructor will follow up with you about this.
Asthma
History of asthma or asthma attacks. Any history of wheezing caused by exercise, anxiety, cold, fatigue, etc. Any condition requiring medication and/or use of an inhaler for control of wheezing.
Your instructor will follow up with you about this.
Diabetes mellitus
Especially Type I Diabetes (Insulin dependent) or Type II Diabetes, which requires insulin or oral medication for control. Any form of Diabetes that is unstable, “brittle” or produces episodes of hypoglycemia, hyperglycemia or if there is related kidney disease, eye disease, heart disease or blood vessel disease.
Your instructor will follow up with you about this.
Pregnancy
If you are currently pregnant.
Your instructor will follow up with you about this.
Freediving / scuba diving conditions
Suffered a barotrauma (pressure-related injury) in the past 4 weeks.
Your instructor will follow up with you about this.
Medication
Any medication taken on a regular basis, either over-the-counter or prescribed by a physician.
Your instructor will follow up with you about this.
General medical problems
Any physical and/or emotional condition not mentioned that might affect your safety in an underwater environment or affect your judgment under times of physical or emotional stress.
Your instructor will follow up with you about this.
Declaration

I certify that I have answered the above questions accurately and honestly. I also declare that I will freedive within the levels of my experience, competence and training with a competent buddy at all times.

Name is required
Please tick the box to confirm
Sign here
Signature is required
Date is required
Please answer all medical questions before continuing.

Liability waiver

Please read carefully, then sign below

Liability release and assumption of risk

I, PARTICIPANT, HEREBY DECLARE THAT I UNDERSTAND THAT FREEDIVING IS AN INHERENTLY RISKY ACTIVITY THAT MAY RESULT IN SERIOUS BODILY INJURY OR DEATH. I KNOWINGLY AND FREELY ACCEPT AND ASSUME ALL RESPONSIBILITY FOR MY PARTICIPATION IN FREEDIVING WITH INSTRUCTOR.

In consideration of INSTRUCTOR allowing me to participate in freediving activities, I hereby fully release and discharge from responsibility INSTRUCTOR and Freedive/Surfcamp Lombok, and their respective officers, directors, agents, contractors and any other individuals connected to or acting on behalf of them (including, without limitation, volunteers and other participants)(collectively the “Released Parties”) from any and all liability, claims, losses or damages related to my participation in any freediving activity including, without limitation, liability, claims, losses or damages resulting from the negligence of any party, including the Released Parties.

I agree that if I, or anyone on my behalf, make any claim or demand against any Released Party in connection with my participation in any freediving activity, I will indemnify and hold harmless each such Released party from any loss, liability, damage or cost incurred as result of such claim or demand.

I declare that I am in good mental and proper physical condition to participate in freediving. I am not under the influence of alcohol or any drugs that are contraindicatory to freediving. I know of no reason why I cannot or should not freedive. I am legally competent to sign this liability release. I understand the terms herein are contractual and not a mere recital, and that I have signed this document of my own free will and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this Liability Release and Assumption of Risk is found to be unenforceable or invalid that provision shall be severed and the remainder of this document will then be construed as though the unenforceable provision was not contained herein.

Parental or Guardian’s Consent (required if PARTICIPANT is under 18 years of age): The undersigned, as the legal parent or guardian of PARTICIPANT, hereby grants permission to PARTICIPANT to participate in freediving activities. The undersigned further agrees to all terms of this Liability Release and Assumption of Risk on behalf of PARTICIPANT and to indemnify and hold harmless the Released Parties from any liabilities incident to PARTICIPANT’s involvement or participation in such activities.

Sign here
Signature is required
Date is required
Confirmation
Please confirm before submitting
Freediving underwater

You’re all set

Your registration is in. Your instructor will confirm your course details and send you everything you need for the day. See you in the water.

Certified through Apnea Total  ·  Gerupuk, South Lombok, Indonesia