Booking Request for Diving CoursesContact InformationName of Contact*Please selectMrMsPrefixFirstLastEmail address*Confirm Email Address*Country code (e.g. +30)*Mobile Phone No.*Your Hotel*Hotel is in Town/Area*Arrival*Departure*Preferred Language*Please selectDutchEnglishFrenchGermanGreekPolishRussianour diving instructors speak Greek, English, German, French, Dutch, Russian, PolishDo you need a transfer to our diving center?*YesNoOur diving center is located in Agia Pelagia, 20 km west of Heraklion. Transfer is free from hotels between Fodele (West) and Malia (East).Medical ConditionsRecreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out evaluation from a physician. For your safety, and that of others who may dive with you, answer all questions honestly.Note to women: If you are pregnant, or attempting to become pregnant, do not dive.I have had problems with my lungs,breathing, heart and/or blood affecting my normal physical or mental performance.I am over 45 years of age.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.I have had problems with my eyes, ears, or nasal passages/sinuses.I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.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 disability.I have had back problems, hernia, ulcers, or diabetes.I have had stomach or intestine problems, including recent diarrhea.I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).Number of Participants123456Participant 1Name*Please selectMrMsPrefixFirstLastAge*Do you suffer from or have a history of any of the medical conditions described above?*yesnoI'm not suremedical condition*Select a Diving CourseScuba DiverUpgrade from Scuba Diver to Open Water DiverOpen Water DiverAdvanced Open Water DiverRescue DiverEmergency First ResponseReferralSelect a Specialty CourseDeep DiverNight DiverNitrox DiverPeak Performance BuoyancySearch and RecoveryU/W NavigatorU/W PhotographerWhat is your Diving Organization*PADI, CMAS, etc.Your Certification Level*Total Number of Dives*Date of last Dive*Reservation Request for (date)*Participant 2Name*Please selectMrMsPrefixFirstLastAge*Do you suffer from or have a history of any of the medical conditions described above?*yesnoI'm not suremedical condition*Select a Diving CourseScuba DiverUpgrade from Scuba Diver to Open Water DiverOpen Water DiverAdvanced Open Water DiverRescue DiverEmergency First ResponseReferralSelect a Specialty CourseDeep DiverNight DiverNitrox DiverPeak Performance BuoyancySearch and RecoveryU/W NavigatorU/W PhotographerWhat is your Diving Organization*PADI, CMAS, etc.Your Certification Level*Total Number of Dives*Date of last Dive*Reservation Request for (date)*Participant 3Name*Please selectMrMsPrefixFirstLastAge*Do you suffer from or have a history of any of the medical conditions described above?*yesnoI'm not suremedical condition*Select a Diving CourseScuba DiverUpgrade from Scuba Diver to Open Water DiverOpen Water DiverAdvanced Open Water DiverRescue DiverEmergency First ResponseReferralSelect a Specialty CourseDeep DiverNight DiverNitrox DiverPeak Performance BuoyancySearch and RecoveryU/W NavigatorU/W PhotographerWhat is your Diving Organization*PADI, CMAS, etc.Your Certification Level*Total Number of Dives*Date of last Dive*Reservation Request for (date)*Participant 4Name*Please selectMrMsPrefixFirstLastAge*Do you suffer from or have a history of any of the medical conditions described above?*yesnoI'm not suremedical condition*Select a Diving CourseScuba DiverUpgrade from Scuba Diver to Open Water DiverOpen Water DiverAdvanced Open Water DiverRescue DiverEmergency First ResponseReferralSelect a Specialty CourseDeep DiverNight DiverNitrox DiverPeak Performance BuoyancySearch and RecoveryU/W NavigatorU/W PhotographerWhat is your Diving Organization*PADI, CMAS, etc.Your Certification Level*Total Number of Dives*Date of last Dive*Reservation Request for (date)*Participant 5Name*Please selectMrMsPrefixFirstLastAge*Do you suffer from or have a history of any of the medical conditions described above?*yesnoI'm not suremedical condition*Select a Diving CourseScuba DiverUpgrade from Scuba Diver to Open Water DiverOpen Water DiverAdvanced Open Water DiverRescue DiverEmergency First ResponseReferralSelect a Specialty CourseDeep DiverNight DiverNitrox DiverPeak Performance BuoyancySearch and RecoveryU/W NavigatorU/W PhotographerWhat is your Diving Organization*PADI, CMAS, etc.Your Certification Level*Total Number of Dives*Date of last Dive*Reservation Request for (date)*Participant 6Name*Please selectMrMsPrefixFirstLastAge*Do you suffer from or have a history of any of the medical conditions described above?*yesnoI'm not suremedical condition*Select a Diving CourseScuba DiverUpgrade from Scuba Diver to Open Water DiverOpen Water DiverAdvanced Open Water DiverRescue DiverEmergency First ResponseReferralSelect a Specialty CourseDeep DiverNight DiverNitrox DiverPeak Performance BuoyancySearch and RecoveryU/W NavigatorU/W PhotographerWhat is your Diving Organization*PADI, CMAS, etc.Your Certification Level*Total Number of Dives*Date of last Dive*Reservation Request for (date)*Message or Special RequestsSENDThis field should be left blank
