LeapScubaAmami Participation Application Form (En) | 奄美大島ダイビングショップ LeapScubaAmami (リープスクーバアマミ)

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📋 Participation Application Form

Common application form for all menus

Please select your participation menu and fill in all fields accurately.

⏱️ Time required: Approx. 3-5 minutes
⚠️ Guardian signature required for participants under 18 years old

Menu *

Fun Diving
Nudibranch Diving
Refresh Diving
Discover Scuba Diving
Snorkeling
PADI Course Open Water
PADI Course Advanced Open Water

Please select the menu you would like to participate in this time.

📄 View Original Application Form PDF (Opens in new window)

Participant Name *

Please enter your full name

Date of Birth *

Please select your date of birth (Year/Month/Day)

Sex *

Male
Female
Other
Prefer not to answer

Age *

Postal Code *

Country *

Currently Address *

Mobile Number with Country Code *

E-mail Address *

Emergency Contact

Emergency Contact Name *

Relationship to Participant *

Emergency Contact Phone Number *

Emergency Contact Address

Diving Experience

Do you have a diving certification? *

Yes (I have a certification)
No (I do not have a certification)

Certified Organizations *

Certification Levels *

Number of Dive Experiences *

Date of Last Dive *

🏥 Diver Medical | Participant Questionnaire

Recreational scuba diving and freediving requires good physical and mental health. Please answer all questions honestly.

If you answer “Yes” to any question, detailed follow-up questions will be displayed.

📄 View Original Diver Medical PDF

Q1：I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *

Q2：I am over 45 years of age. *

Q3：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. *

Q4：I have had problems with my eyes, ears, or nasal passages/sinuses. *

Q5：I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. *

Q6：I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. *

Q7：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. *

Q8：I have had back problems, hernia, ulcers, or diabetes. *

Q9：I have had stomach or intestine problems, including recent diarrhea. *

Q10：I am taking prescription medications (with the exception of birth control or or anti-malarial drugs other than mefloquine (Lariam). *

BOX A – I HAVE/HAVE HAD:

Please answer the following questions

A-1：Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and/or chronic lung disease. *

A-2：Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise. *

A-3：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. *

A-4：Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. *

A-5：Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance. *

BOX B – I AM OVER 45 YEARS OF AGE AND:

Do any of the following apply to you?

B-1：I currently smoke or inhale nicotine by other means. *

B-2：I have a high cholesterol level. *

B-3：I have high blood pressure. *

B-4：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). *

BOX C – I HAVE/HAVE HAD:

Please answer the following questions

C-1：Sinus surgery within the last 6 months. *

C-2：Ear disease or ear surgery, hearing loss, or problems with balance. *

C-3：Recurrent sinusitis within the past 12 months. *

C-4：Eye surgery within the past 3 months. *

BOX D – I HAVE/HAVE HAD:

Please answer the following questions

D-1：Head injury with loss of consciousness within the past 5 years. *

D-2：Persistent neurologic injury or disease. *

D-3：Recurring migraine headaches within the past 12 months, or take medications to prevent them. *

D-4：Blackouts or fainting (full/partial loss of consciousness) within the last 5 years. *

D-5：Epilepsy, seizures, or convulsions, OR take medications to prevent them. *

BOX E – I HAVE/HAVE HAD:

Please answer the following questions

E-1：Behavioral health, mental or psychological problems requiring medical/psychiatric treatment. *

E-2：Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment. *

E-3：Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation. *

E-4：An addiction to drugs or alcohol requiring treatment within the last 5 years. *

BOX F – I HAVE/HAVE HAD:

Please answer the following questions

F-1：Recurrent back problems in the last 6 months that limit my everyday activity. *

F-2：Back or spinal surgery within the last 12 months. *

F-3：Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. *

F-4：An uncorrected hernia that limits my physical abilities. *

F-5：Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. *

BOX G – I HAVE HAD:

Please answer the following questions

G-1：Ostomy surgery and do not have medical clearance to swim or engage in physical activity. *

G-2：Dehydration requiring medical intervention within the last 7 days. *

G-3：Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. *

G-4：Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). *

G-5：Active or uncontrolled ulcerative colitis or Crohn's disease. *

G-6：Bariatric surgery within the last 12 months. *

⚠️ For Those Requiring Physician Evaluation

Medical certificate from physician required if any of the following apply:

Answered “Yes” to Q3 (exercise ability)
Answered “Yes” to Q5 (surgery)
Answered “Yes” to Q10 (prescription medications)
Answered “Yes*” (with asterisk) to any detailed questions in Boxes A-G

If applicable, select submission method below. If not applicable, skip this section and click “Next”.

Medical Certificate Submission Method

Upload from smartphone/PC
Submit original or copy at the dive center on the day

Medical Certificate (PDF, Image)

Drag & Drop Files, Choose Files to Upload

Please upload medical certificate from physician (PDF, JPG, PNG format)

📋 Standard Safe Diving Practices Statement of Understanding

This statement informs you of established safe diving practices. Please read carefully before agreeing.

📄 View Original Safe Diving Practices Statement PDF

I, __________, understand that as a diver I should:

PADI Safe Diving Practices *

1.Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and refresh myself on important information.

PADI Safe Diving Practices Q2 *

2.Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which I am experienced, postpone diving or select an alternate site with better conditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave or technical diving unless specifically trained to do so.

PADI Safe Diving Practices Q3 *

3.Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correct fit and function prior to each dive. Have a buoyancy control device, low-pressure buoyancy control inflation system, submersible pressure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—whichever you are trained to use) when scuba diving. Deny use of my equipment to uncertified divers.

PADI Safe Diving Practices Q4 *

4.Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recognize that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed six months.

PADI Safe Diving Practices Q5 *

5.Adhere to the buddy system throughout every dive. Plan dives – including communications, procedures for reuniting in case of separation and emergency procedures – with my buddy.

PADI Safe Diving Practices Q6 *

6.Be proficient in dive planning (dive computer or dive table use). Make all dives no decompression dives and allow a margin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 metres/60 feet per minute. Be a SAFE diver – Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer.

PADI Safe Diving Practices Q7 *

7.Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving. Carry at least one surface signaling device (such as signal tube, whistle, mirror).

PADI Safe Diving Practices Q8 *

8.Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessive hyperventilation when breath-hold diving. Avoid overexertion while in and underwater and dive within my limitations.

PADI Safe Diving Practices Q9 *

9.Use a boat, float or other surface support station, whenever feasible.

PADI Safe Diving Practices Q10 *

10.Know and obey local dive laws and regulations, including fish and game and dive flag laws.

I understand the importance and purposes of these established practices. I recognize they are for my own safety and well-being, and that failure to adhere to them can place me in jeopardy when diving.

🏊 Snorkeling Tour Pre-participation Agreement (Adult – 20 years and older)

Please read and agree to the following before participating:

📄 View Original Agreement PDF (Adult)

I have read and understood the Snorkeling Tour Pre-participation Agreement and agree to participate. I understand that this program will be conducted in the ocean, pool, or similar water environment. Therefore, I agree to follow the instructions of the guide or instructor for safety. I am aware that this program is a sport and that participation requires good health. In particular, I understand that there are no issues related to ear or respiratory system problems, circulatory system disorders, or any past medical history. I also understand that if I have not taken prescription medications, my physical condition is good and healthy, and that participation in this program is conditional upon these factors. I fully understand that to safely enjoy the program, I must comply with the above conditions. I also understand that if I do not follow the instructions of the instructor or guide, or fail to disclose serious medical conditions, and an accident occurs as a result, it is entirely my responsibility.

🏊 Snorkeling Tour Pre-participation Agreement (Minor – 12 to 20 years old · Guardian and Participant Agreement)

Both guardian and participant must read and agree to the following:

📄 View Original Agreement PDF (12-20 years old)

I (guardian) and my child have read and understood the Snorkeling Tour Pre-participation Agreement and agree to participate. I (guardian) and my child understand that this program will be conducted in the ocean, pool, or similar water environment. Therefore, we agree to follow the instructions of the guide or instructor for safety. I/My child am/is aware that this program is a sport and that participation requires good health. In particular, there are no issues related to ear or respiratory system problems, circulatory system disorders, or any past medical history related to me/my child. I/My child have/has not taken prescription medications, and my/my child’s physical condition is good and healthy, which is a condition for participation in this program. I/My child fully understand that to safely enjoy the program, the above conditions must be met. I/My child also understand that if I/my child do/does not follow the instructions of the instructor or guide, or fail to disclose serious medical conditions, and an accident occurs as a result, it is entirely my/my child’s responsibility.

🏊 Snorkeling Tour Pre-participation Agreement (Minor – Under 12 years old · Guardian Agreement)

Guardian must read and agree to the following:

📄 View Original Agreement PDF (Under 12 years old)

I (guardian) certify that my child has read and understood the Snorkeling Tour Pre-participation Agreement and agrees to participate. I understand that this program will be conducted in the ocean, pool, or similar water environment. Therefore, my child agrees to follow the instructions of the guide or instructor for safety. My child is aware that this program is a sport and that participation requires good health. In particular, there are no issues related to ear or respiratory system problems, circulatory system disorders, or any past medical history related to my child. My child has good physical and mental health. My child has not taken prescription medications, and my child’s physical condition is good and healthy, which is a condition for participation in this program. My child fully understands that to safely enjoy the program, the above conditions must be met. My child also understands that if my child does not follow the instructions of the instructor or guide, or I fail to disclose serious medical conditions about my child, and an accident occurs as a result, it is entirely my child’s and my responsibility.

Diving stomach that

Use of Photos and Videos for SNS and Blogs *

May we use the photos and videos taken on the day for social networking, websites, advertisements?

📄 PADI Liability Release and Assumption of Risk (All Menus)

Acknowledging that skin diving and scuba diving carry inherent risks of serious injury or death, please read, understand, and agree to the following:

📄 View Original PADI Liability Release PDF

Agreement to PADI Liability Release *

I hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. I understand that diving with compressed air involves certain inherent risks; including but not limited to decompression sickness, embolism or other hyperbaric/air expansion injury that require treatment in a recompression chamber. I understand and agree that neither my instructor(s), the facility through which I receive my instruction, nor PADI Americas, Inc., nor its affiliate and subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occur as a result of my participation in this diving program. I understand the terms herein are contractual and not a mere recital, and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights.

Signature of Participant

署名をクリアー

Please read carefully before signing.

Date *

Signature of Parent/Guardian

署名をクリアー

If you are under 20 years of age, a parent or guardian’s signature is required.

Date *