AFC - Membership 2018/19 Signup Form
This is the form to use to sign up to a full membership with the AFC.
First Name *
Your answer
Second Name *
Your answer
Email Address *
Your answer
What are you wanting to register for? *
Membership benefits can be viewed here: http://aucklandfreediving.co.nz/join/
Gender *
Required
New Member and need an induction? *
Required
FaceBook Member? *
Required
Date of Birth *
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Address *
Your answer
Cell Phone Number *
Your answer
Work Phone Number
Your answer
Home Phone Number
Your answer
Emergency Contact Details - Name *
Your answer
Emergency Contact Details - Relationship
Your answer
Emergency Contact Details - Cell Phone Number *
Your answer
Emergency Contact Details - Home Phone Number
Your answer
Emergency Contact Details - Work Phone Number
Your answer
Emergency Contact Details - Email
Your answer
Emergency Contact Details - Address *
Your answer
Any other important information for the club to be aware of:
Your answer
AFC - Liability and Release Form
New Member Liability and Release form.
I hereby affirm that I have been thoroughly informed of the risk involved with any freediving / breath-hold activity *
Required
I understand that freediving / breath-holding underwater may involve inherent risks including but not limited to hypoxia, marine life injuries, barotraumas, shallow water blackout, drowning or hyperbaric accidents. Treatment of freediving / breath-hold diving accident victim with these ot other injuries may require immediate medical attention and /or hyperbaric oxygen therapy. *
Required
I specifically understand that the risk of shallow water blackout is inherent of freediving /breath-holding activities, and that I still intend to participate in freediving / breath-hold diving. I agree that I will not freedive / breath-hold alone; I will always freedive with a suitably trained and experienced freediving buddy at all times. *
Required
I understand that neither the Auckland Freediving Club, nor their respective members, nor their respective officers, agents and employees (hereinafter referred to as "Released Parties") may be held liable or responsible in anyway for any injury, death or other damages to myself, my family, heirs or assigns that may occur as a result of my participation in this freediving / breath-holding or as a result of the negligence of any party, including the Released Parties, whether passive or active. *
Required
I agree to abide by the Auckland Freediving Club Safety Protocol. (See AFC website for full document). *
Required
I agree to hold harmless the Released Parties from any claim or lawsuit by myself, my family, estate, heirs or assigns, arising during, or after I complete the freediving/ breath-holding course, training or event *
Required
I understand that any diving activities are physically strenuous and that I will be exerting myself during this freediving / breath-holding, and I expressly assume the risk of any and all injuries, and I will not hold the Released Parties responsible if I am injured as a result of heart attack, panic, hypoxia, hyperventilation, oxygen toxicity, decompression illness, gas embolism, drowning or any other causes of injury or death not specifically stated herein. *
Required
It is my intention by filling in this form to exempt and release all of the Released Parties as defined herein, from all liability whatsoever for personal injury, property damage or wrongful death however caused, including but not limited to the negligence of the Released Parties whether active or passive. *
Required
I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF RISK BY READING IT BEFORE SUBMITTING IT ON BEHALF OF MY HEIRS AND MYSELF *
Required
I consent to the capture and secure storage of these details, including access by the senior members who run club training sessions. *
Required
I consent to my contact details and membership status details being forwarded to Freediving New Zealand, so that if applicable, I can be provided membership to that organisation *
Required
I have read this agreement, understood it & I agree to be bound by it & consent for any child / ward to participate in freediving activities. *
Required
I have made payment into the club account (Branch: ANZ, Account: Auckland Freediving Club, Account: 01-1844-0012460-46) *
Required
Enter Participant Name (or Guardian where applicable) as consent *
Your answer
Date of Consent *
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AFC - Medical Statement
Important: Please read carefully before filling out.

Freediving is a strenuous activity carried out in the underwater environment, which may, under certain conditions, increase your risk of injury. This risk may be significantly increased if you have certain medical conditions. This statement has bean developed to make you aware of these conditions. The purpose of a medical statement is to find out, if you should be examined by a doctor before participating in any Freediving activity events. Please read each question carefully and answer them accurately.

Please explain any “yes” answer.

A positive answer will not necessarily exclude you from participating in any Auckland Freediving Club endorsed events / training competitions. But it will require a medical clearance from a physician. This form and your answers will be kept confidential.

Medical History *
Yes
No
1 NEUROLOGICAL CONDITIONS - Any history of seizure disorder, stroke, brain surgery, black out, severe migraine headaches, or aneurysm of the brain’s blood vessels. 
2 CARDIOVASCULAR CONDITIONS - Heart attack, heart surgery, irregular heart beat, uncontrolled elevated blood pressure.
3 PULMONARY CONDITIONS - Any history of spontaneous collapsed lung, collapsed lung due to injury, cysts or air pockets of the lungs, damage to lung tissue, emphysema, or any lung problem which interferes with your ability to breath.
4 EAR CONDITIONS - Permanent holes of the eardrums, history of ruptured eardrum, severely impaired hearing or hearing loss in one or both ears, or ear surgery.
5 SINUS CONDITIONS - Tumor, polyps, cysts of the sinus cavities or nasal passages, sinus surgery, or persistent sinus infections.
6 ASTHMA - History of asthma or asthma attacks, history of wheezing caused by exercise, anxiety, cold, fatigue, etc. Any conditions requiring medications and/or use of an inhaler for control of wheezing.
7 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 or produces episodes of hypoglycaemia (low blood sugar reactions) hyperglycemia (extremely high blood sugar) or if there is related kidney disease, eye disease, heart disease or blood vessel disease. Also, of history of elevated blood sugar during pregnancy.
8. PREGNANCY - Are you presently pregnant
9. FREEDIVING / SCUBA DIVING CONDITIONS - Previous history of a diving accident, decompression sickness, decompression of the inner ear or air embolus 
10 MEDICATION - Do you take any medication on a regular basis either over the counter or prescribed by a physician
11 GENERAL MEDICAL PROBLEMS - Any physical and / or emotional condition not mentioned that might effect your safety in an underwater environment or affect your judgment under times of physical or emotional stress
12 RECENT ILL HEALTH - You should not participate in apnea activities until fully recovered from ill health.
If you answered yes to any of the previous questions, please elaborate further. Note: If you have ticked "yes" to any medical condition and you do not acquire a medical, you will not be able to attend any training sessions (no exceptions).
Your answer
The information I have provided about my medical history is accurate to the best my knowledge. *
Required
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