Membership Form

To be a member of Scavenger Dive Boat club, please complete the following form;

Name(required)

Email(required)

Phone Number(required)

Full Address including Postcode(required)

Date of Birth(required)

Diving Qualification and Agency(required)

Next of Kin Name and contact number(required)

Medical Questions (please read the questions and choose one or the other options at the end);

Have you ever suffered at any time from diseases of the heart and circulation including high blood pressure (or taking tablets for high blood pressure), angina, chest pains or palpitations?
Have you ever had chest or heart surgery?
Have you ever had significant bleeding or blood disorders?
Have you ever suffered from asthma, chronic obstructive airways disease or ever used an inhaler?
Have you ever had collapsed lung, pneumothorax or other lung injury?
Have you ever had any other problem affecting the lungs, suspected or known COVID-19 or tested positive for COVID-19?
Have you ever suffered from blackouts, fainting or recurrent dizziness?
Have you ever had abdominal surgery, Ileostomy, colostomy or repair of a hiatus hernia?
Have you ever had epilepsy or fits?
Have you ever had recurrent migraines?
Have you ever had any other disease of the brain or nervous system (including strokes or multiple sclerosis)?
Have you had back or spinal surgery or any serious back problems?
Have you ever had psychological illness of any kind, fear of small spaces, suicidal thoughts or panic attacks?
Do you have diabetes?
Have you ever had cancer, malignant disease or a tumour?
Have you ever had a requirement for any prescribed medication (except the contraceptive pill)?
Have you ever had, or been treated for, decompression illness, immersion induced pulmonary oedema or other diving related problem??
Have you had regular ear problems in the past ten years?
Have you had a head injury with loss of consciousness in the past 5 years?
Have you had any problem with alcohol or drug abuse in the last five years?
Have you ever been refused a diving medical certificate or life insurance or been offered special terms?
Are you currently receiving medical care or have you consulted a doctor in the last year other than for mild self limiting illnesses that have completely resolved? (Please discuss any symptoms of the upper or lower respiratory tract including Covid19 with a UKDMC Medical Referee).
Are you concerned about any other medical issue that has not been covered by the questions on this page?

Medical Declarations choose just one option(required)

When is your first trip planned with the club?(required)

Declarations;

I confirm that all of the information that I have provided in this form is accurate and correct at the time of joining the Scavenger Dive Boat Club. I fully understand that the payments I am making are a contribution to the direct expenses of the operation of the vessel incurred during the planned dive trip. That Scavenger Dive Boat club is a members' club formed for the purpose of sport or pleasure which, at the time it is being used, is used only for the sport or pleasure of members of that club or their immediate family, and for the use of which any charges levied are paid into club funds and applied for the general use of the club; and no other payments are made by or on behalf of users of the vessel, other than by the owner. I accept that the club insurance covers me whilst on the boat for all the diving activities linked to Scavenger Dive Boat club, however I am aware that liabilities to me as a diver are excluded from the time of going overboard until safely back onboard. I consent to Scavenger Dive Boat Club collecting and storing my personal information in order to process my boat diving club membership with them. (GDPR Compliance)(required)

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