PLEASE NOTE: THIS FORM MUST BE SIGNED AND NOTARIZED. THIS FORM HAS FOUR PAGES.

NAME_______________________________________________________________________________________ FIRST MIDDLE LAST

BIRTH DATE _______________________________ AGE AT TIME OF PROGRAM _________ SEX _____ SCHOOL/GROUP ____________________________________ PROGRAM DATES_____________________________ ADDRESS_______________________________________________________________________________________ CITY, STATE, ZIP________________________________________________________________________________ CELL PHONE_____________________________ EMAIL ________________________________________________

PERSON TO CONTACT IN AN EMERGENCY ___________________________________________________________ RELATIONSHIP ___________________________________________________________________________________ CELL PHONE_____________________________________________________________________________________

SPECIAL DIETARY NEEDS OR ALLERGIES:

Vegetarian No red meat No pork Gluten‐free Dairy‐free Vegan Peanut Allergy (severity): __________________________________________________________________________________

Other dietary notes: ________________________________________________________________________________________

MY HEALTH/ACCIDENT POLICY IS WITH ______________________________________________________________

POLICY NUMBER: _______________________________ POLICYHOLDER NAME: ____________________________

PHONE NUMBER: _________________________________________________________________________________

I give permission for MRDF staff to take photos or videos of my child par cipa ng in these ac vi es, which will remain the property of MRDF to be used in public promo ons. NO YES

YOU MUST COMPLETE THE MEDICAL QUESTIONNAIRE ON THE NEXT PAGE. YOU MUST FILL IN THE WORD “YES” OR “NO” FOR EACH

QUESTION. IF YOU ANSWER YES TO ANY OF THE QUESTIONS, PLEASE CONTACT MARINELAB TO OBTAIN A PHYSICIAN’S APPROVAL FORM

AND MEDICAL GUIDELINES INFORMATION TO PROVIDE YOUR PHYSICIAN. WHEN REQUIRED, A PHYSICIAN’S APPROVAL FORM MUST BE

PROVIDED TO MARINELAB PRIOR TO THE FIRST DAY OF PROGRAM ACTIVITIES. PARTICIPANTS WHO FAIL TO PROVIDE A PHYSICIAN AP‐

PROVAL FORM, IF REQUIRED, WILL NOT BE ALLOWED TO DIVE USING COMPRESSED AIR.

PARTICIPANT INFORMATION

EMERGENCY CONTACT INFORMATION

DIETARY & MEDICAL INFORMATION

MarineLab SCUBA Program Information & Liability Release for MINORS

The purpose of this Medical Ques onnaire is to find out if you should be examined by your doctor before par cipa ng in MarineLab’s

dive program. A posi ve response to a ques on does not necessarily disqualify you from diving. A posi ve response means that there is

a preexis ng condi on that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive

ac vi es.

 Please answer the following ques ons on your past or present medical history with a YES or NO (you MUST write in the word “yes’ or “no’ for each ques on). If you are not sure, answer YES. If YOU ANSWER YES TO ANY OF THESE QUESTIONS, you must consult with a physician and obtain physician’s approval to dive prior to par cipa ng in MarineLab’s scuba diving program. We will supply you with a Medical Statement and Guidelines for Recrea onal Scuba Diver’s Physical Examina on to take to your physician. Do you have allergic reac ons severe enough to need an epi‐pen? If so, make sure you bring it! Could you be pregnant, or are you a emp ng to become pregnant? Are you presently taking prescrip on medica ons? (with the excep on of birth control or an ‐malarial) Please list these medica ons: ________________________________________________________________________ Have you ever had or do you currently have (YOU MUST WRITE YES OR NO)

Asthma, or wheezing with breathing, or wheezing with exer‐cise?

Frequent or severe a acks of hayfever or allergy?

Frequent colds, sinusi s or bronchi s?

Any form of lung disease?

Pneumothorax (collapsed lung)?

Other chest disease or chest surgery?

Behavioral health, mental or psychological problems (Panic a ack, fear of closed or open spaces)?

Epilepsy, seizures, convulsions or take medica ons to prevent them?

Recurring complicated migraine headaches or take medica‐ons to prevent them?

Blackouts or fain ng (full/par al loss of consciousness)?

Frequent or severe suffering from mo on sickness (seasick, carsick, etc.)?

____ Dysentery or dehydra on requiring medical interven on?

____ Any dive accidents or decompression sickness?

Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?

Head injury with loss of consciousness in the past five years?

Recurrent back problems?

Back or spinal surgery?

Diabetes?

Back, arm or leg problems following surgery, injury or frac‐ture?

____ High blood pressure or take medicine to control blood pres‐sure? Heart disease?

Heart a ack?

Angina, heart surgery or blood vessel surgery?

Sinus surgery?

Ear disease or surgery, hearing loss or problems with balance?

Recurrent ear problems?

Bleeding or other blood disorders?

____ Hernia?

____ Ulcers or ulcer surgery ?

A colostomy or ileostomy? Recrea onal drug use or treatment for, or alcoholism in the

past five years?

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.

NAME OF PARTICIPANT: ____________________________________________________________ __________________________________ ____________________________________________ ________________________ Participant Signature Signature of Parent or Guardian Date

MEDICAL QUESTIONNAIRE Minor Student SCUBA Informa on & Liability Release Form Page 2 of 4 

PAGE MarineLab/MRDF ASSUMPTION OF RISKS, LIABILITY RELEASE & HOLD HARMLESS CONTRACT MarineLab/MRDF is a not-for-profit, non-commercial, home, private and public school / community oriented education pro-gram. MarineLab/MRDF educational programs offer rewarding experiences to develop Participant’s knowledge and skills essential to understanding marine sciences and resources. In consideration of myself or my child (PARTICIPANT) being al-lowed to participate in the Program Activities I HEREBY AGREE TO BE CONTRACTUALLY BOUND BY THE FOLLOWING:

NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN (Pursuant to Florida Statutes § 774.301)

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF MarineLab/Marine Resources Development Foundation, Inc., Key Largo Undersea Park, Inc., Roland Creese LLC d/b/a Island Ventures, their boats (whether owned, operated, leased, or chartered), their owners, directors, spon-sors, agents, employees, volunteers, instructors, assistants, educational groups, individuals and all others in connection with Program Activities, whether specifi-cally named or not (herein “Released Parties”) USE REASONABLE CARE IN PROVID-ING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGN-ING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RE-COVER FROM THE RELEASED PARTIES IN A LAWSUIT FOR ANY PERSONAL INJURY, IN-CLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE RELEASED PARTIES HAVE THE RIGHT TO RE-FUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM. In consideration of being allowed to participate in the Program Activities I HEREBY AGREE TO BE CONTRACTUALLY BOUND BY THE FOLLOWING:

Contract Parties: On behalf of MYSELF, MY MINOR CHILD, OUR FAMILY, HEIRS, ASSIGNS, REPRESENTATIVES & ALL OTH-ERS WHO MAY HAVE A CLAIM ON MY OR MY MINOR CHILD’S BEHALF (hereafter “I” or “Participant”), I voluntarily enter into this contract with MarineLab/Marine Resources Development Foundation, Inc., Key Largo Undersea Park, Inc., RolandCreese LLC d/b/a Island Ventures, boats (whether owned, operated, leased, or chartered), their owners, directors, spon-sors, agents, employees, volunteers, instructors, assistants, educational groups, individuals and all others in connection with Program Activities, whether specifically named or not (hereafter “Released Parties”).

Participant Responsibilities & Assumption of Risks: I am a certified diver or a student under the supervision of my dive instructor. I understand there are inherent risks of serious injury, illness and death associated with swimming, snorkeling, breath-hold diving, scuba diving, hookah diving, underwater habitats, boating, entering/exiting the water and related aquatic educational activities (herein “Program Activities”). I will use all safe diving practices, plan my dive, remain with my dive partner, maintain situational and self awareness, and use my good judgment to reduce these risks, however, I know the risk of serious injury, illness and death cannot be completely eliminated. It is my responsibility to inspect my equipment prior to each dive and to monitor my gas supply throughout my dive. I accept sole responsibility for the function and adequacy of the equipment and breathing gases I use. I understand Program Activities will expose me to risk of panic, drowning, stings, bites, infections, decompression illness, overexpansion injuries, pressure related injuries, breathing gas toxicities, dangerous environmental conditions, etc., and boating will expose me to risk of unexpected movement, danger-ous environmental conditions, fire, capsize, sinking, grounding, abandonment, collision, being struck by a boat, hazards of the sea, etc. My participation in Program Activities is voluntary and if I do not feel capable or competent, then I will refrain from that activity. I agree to be solely responsible for my health and safety. DESPITE THE RISK OF SERIOUS INJURY, ILL-NESS & DEATH, I VOLUNTARILY CHOOSE TO PARTICIPATE IN PROGRAM ACTIVITIES AND ASSUME ALL RISKS, WHETHER FORESEEN OR UNFORESEEN, AND WHETHER CREATED OR NOT BY THE RELEASED PARTIES, ASSOCIATED WITH MY PAR-TICIPATION IN PROGRAM ACTIVITIES.

Minor Student SCUBA Informa on & Liability Release Form Page 3 of 4 NAME OF PARTICIPANT:___________________________________

Participant’s Condition & Insurance: I will abide by all MarineLab/MRDF policies, rules and regulations. I will dive within my abilities. If I do not feel well or become aware of any unsafe condition, I will refrain from participation. I am physically, medically and mentally fit to dive. I will not hold anyone responsible for any condition I may suffer that results in my inju-ry, illness or death. I will not possess nor consume alcohol, tobacco or drugs (other than those prescribed to me by a physi-cian) while participating in Program Activities. I understand Program Activities may be conducted at remote locations dis-tant from emergency response, medical care and hyperbaric care. I AUTHORIZE RELEASED PARTIES TO PROVIDE EMER-GENCY FIRST AID & MEDICAL CARE. I AGREE TO BE SOLELY RESPONSIBLE AND PAY FOR ALL EXPENSES ASSOCIATED WITH MEDICAL CARE. I ASSUME THESE RISKS & HEREBY RELEASE RELEASED PARTIES FOR FAILURE TO RESCUE OR PRO-VIDE PROPER EMERGENCY RESPONSE OR MEDICAL CARE.

Release of Liability: In considerations of being allowed to participate in Program Activities, I HEREBY AGREE TO FOREVER RELEASE THE RELEASED PARTIES FROM ANY & ALL LIABILITY ARISING AS A RESULT OF INJURY, ILLNESS OR DEATH DUE TO ANY ACT OR OMISSION, INCLUDING BUT NOT LIMITED TO NEGLIGENCE ON THE PART OF ANYONE, INCLUDING THE RELEASED PARTIES. THIS IS A COMPLETE & UNCONDITIONAL RELEASE OF ALL LIABILITY OF RELESED PARTIES TO THE GREATEST EXTENT ALLOWED BY LAW.

Hold Harmless & Indemnification: I AGREE TO HOLD HARMLESS, DEFEND & INDEMNIFY (DEFEND & PAY ANY JUDGMENT, COURT COSTS, DAMAGES, INVESTIGATION COSTS, ATTORNEYS’ FEES, & ALL OTHER EXPENSES INCURRED THAT RELATE TO ENFORCEMENT OF THIS CONTRACT) RELEASED PARTIES FROM ANY & ALL CLAIMS, CAUSES OF ACTION OR LAWSUITS ARISING FROM MY PARTICIPATION IN PROGRAM ACTIVITIES. I HEREBY OBLIGATE MYSELF OR MY ESTATE TO BE FULLY RESPONSIBLE TO PAY FOR COSTS ASSOCIATED WITH ANY CLAIM, CAUSE OF ACTION, LAWSUIT OR JUDGMENT AGAINST RELEASED PARTIES AS A RESULT OF MY PARTICIPATION IN PROGRAM ACTIVITIES.

Contract, Governing Law & Severability: This is a contract giving up Participant’s legal rights. This contact shall be in full legal force from the time the Participant signs it, through the duration of all Program Activities, and into the future until all claims, causes of action or lawsuits against Released Parties arising as a result of Program Activities are fully resolved. Participant agrees that any legal action arising as a result of Program Activities shall be governed by Florida State laws and Monroe County shall be the exclusive venue and jurisdiction of any legal action. If any portion of this contract is found to be unenforceable or invalid, then that portion shall be severed and the remainder shall continue in full legal force. I VOL-UNTARILY ENTER INTO THIS CONTRACT BASED EXCLUSIVELY ON THE PREPRINTED TERMS OF THE CONTRACT WITHOUT MODIFICATION OR RELYING ON ANY OTHER REPRESENTATIONS. I AGREE TO BE BOUND BY THIS CONTRACT & I FULLY UNDERSTAND I AM GIVING UP MY LEGAL RIGHTS TO THE FULLEST EXTENT ALLOWED BY LAW.

BY MY SIGNATURE I CERTIFY THAT I AM THE NATURAL GUARDIAN OF THE PARTICIPANT MINOR AND THAT I WILL BE RESPONSI-BLE IN ALL RESPECTS FOR THE PARTICIPANT MINOR AS RELATED TO ANY OBLIGATIONS OR LIABILITIES, CREATED OR IN-CURRED, AS A RESULT OF PARTICIPANT MINOR’S PARTICIPATION IN RELEASED PARTIES’ PROGRAM ACTIVITIES. I HEREBY AU-THORIZE MARINER’S HOSPITAL OR ANY OTHER PERSONNEL TO PROVIDE EMERGENCY MEDICAL CARE TO MY PARTICIPANT MI-NOR. I HAVE READ AND FULLY UNDERSTAND AND AGREE TO BE BOUND BY THIS CONTRACT FOR MYSELF (herein referred to as “I” or “Participant”) AND MY PARTICIPANT MINOR. I UNDERSTAND BY SIGNING THIS CONTRACT I AM GIVING UP LE-GAL RIGHTS FOR MYSELF, MY PARTICIPANT MINOR AND ALL OTHERS WHO MAY HAVE A CLAIM AGAINST RELEASED PAR-TIES AS A RESULT OF PARTICIPATION IN PROGRAM ACTIVITIES. NAME OF PARTICIPANT MINOR: ______________________________________________________________ __________________________________________ ___________________________________________________ ________________ Natural Guardian Name (Print) Signature of Natural Guardian Date THIS FORM MUST BE NOTARIZED! This person is [ personally known ] or [ provided identification ]: Driver’s License #:_________________ Notary Signature: _________________________________________ Notary Stamp Notary Name (Printed): _____________________________________ Date: __________ Commission #: _______________________ My commission expires: ________________

Minor Student SCUBA Informa on & Liability Release Form Page 4 of  4 NAME OF PARTICIPANT:___________________________________