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Microsoft word - application for renewed membership 2009c.doc

Caledonia House, 1 Redheughs Rigg, South Gyle, Edinburgh, EH12 9DQ Tel/Fax: 0131-625-4404 Email: hq@scotsac.com Website: www.scotsac.com Membership Subscription Renewal
I/We enclose my/our annual subscription for continued membership of the Scottish Sub Aqua Club (ScotSAC) for 12 months. I/we am/are member(s) of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Branch. Class of membership applied for (please tick); Family membership covers up to 4 people
(children up to the age of 18 years only). Students please enclose a copy of your matriculation card.
No late renewal fee. If your membership is more than 6 months
late, your next renewal date will be 12 months after payment. Cheques & postal orders payable to “Scottish Sub-Aqua Club”
Please give details of all applicants (should be existing ScotSAC members plus new children, spouse etc) Tick this box if you do not want your email address adding to the ScotSAC mailing list. Your details wil only be used by ScotSAC personnel and no information wil be passed to any other agency or party. To help maintain our records please enter details of any qualification gained since your last renewal. Please enclose photocopies of relevant logbook sections, signed by your Branch Diving Officer and Regional Coach New/Recent Qualification ScotSAC will use and process information provided in accordance with the requirements of the Data Protection Act 1998. The information you provide to us may be held on files, both paper and electronic. We will endeavour to keep your personal data safe and secure. Please note that by signing the application form you are giving explicit consent for the data collected about you to be recorded and used for those purposes. You also agree to abide by ScotSAC Child Protection Code of Conduct, as illustrated in the ScotSAC Child Protection Policy, (www.scotsac.com) . Members are reminded that they are not covered by ScotSAC Third Party Liability Insurance if their Membership is late or lapsed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: Complete this form and send it to: The Treasurer, Scottish Sub Aqua Club, Caledonia House, 1 Redheughs Rigg, South Gyle, Edinburgh, EH12 9DQ - Medical Declaration completed in full - students - a photocopy of your matriculation card - photocopies of logbook sections for qualifications gained since last renewal - a cheque or postal order covering the annual subscription fee (see above) of £ . . . . . . . . . . . . . (please make payable to “Scottish Sub-Aqua Club” and cross “a/c payee only”). Registered in Scotland No. SC313935 VAT No. 596708289 The Scottish Sub Aqua Club is a Company Limited by Guarantee Registered Office: Caledonia House, 1 Redheughs Rigg, South Gyle, Edinburgh, EH12 9DQ Equity Profile Questionnaire
ScotSAC is committed to implementing the Equity Standard: A Framework for Sport. In order to achieve the Foundation Level of the Standard, we are required to carr y out an audit to ascertain the equity profile of our members. This audit will enable us to identify any u nder-represented gro ups or pot ential ar eas of in-eq uity i n the org anisation a nd to ta ke actio n to a ddress a ny Please be ass ured you will not be ide ntified from ans wers you provide and the returne d questionnaires will be see n only by our administration staff. All data will be proc essed in line with the Data Pr otection Act 1998, as set out in our Privac y and Data Protection policy, which is available from www.scotsac.com .
Each member should complete a section (additional members please complete an additional page)

Member 1 -
Please enter your date of birth: / /
Ethnic Origin – please tick the appropriate box to indicate your cultural background
Asian, Asian Scottish or
Black, Black Scottish or Black
Asian British
Disability - The Disability Discrimination Act 1995 defines a disabled person as anyone with a ‘physical or mental impairment that
has a substantial and long-term adverse effect upon his /her ability to carry out normal day – to day activities’. If you consider yourself to have a disability please tick the appropriate box. If yes, please indicate which category your disability falls into:
Member 2 -
Please enter your date of birth: / /
Ethnic Origin – please tick the appropriate box to indicate your cultural background
Asian, Asian Scottish or
Black, Black Scottish or Black
Asian British
Disability - The Disability Discrimination Act 1995 defines a disabled person as anyone with a ‘physical or mental impairment that
has a substantial and long-term adverse effect upon his /her ability to carry out normal day – to day activities’. If you consider yourself to have a disability please tick the appropriate box. If yes, please indicate which category your disability falls into: Thank you for taking the time to complete this questionnaire. Registered in Scotland No. SC313935 VAT No. 596708289 The Scottish Sub Aqua Club is a Company Limited by Guarantee Registered Office: Caledonia House, 1 Redheughs Rigg, South Gyle, Edinburgh, EH12 9DQ CONFIDENTIAL February 2005
UK SPORT DIVER MEDICAL FORM
Any fee in respect of the medical examination is the responsibility of the person being examined.
Diving training must not be undertaken until the candidate has completed a Medical
Declaration or had a Medical Examination confirming fitness to dive
NOTES TO DIVER
Before anyone can undertake diver training, it is necessary for him or her to have completed this medical declaration. If he or she answers”Yes” to
any question they must contact a medical referee (listed on the last page of this form) which may result in a medical examination. Exceptional
fitness is not essential; both men and women can dive safely providing they are reasonably fit and do not suffer from any of the possible
disqualifying conditions listed in the questionnaire. Sport diving can at times involve heavy physical exertion. Moreover, recreational diving in the
UK is carried out in what can occasionally be a cold, dark and hostile environment and it entails responsibility for the safety of other divers.
MEDICAL STANDARDS
A reference table describing the more common medical conditions which may cause problems for divers or may disqualify them from diving
altogether is set out on the inside pages.
CERTIFICATE OF FITNESS TO DIVE
If you have to see a Medical Referee and are found fit to dive, they will give you a completed Certificate of Fitness to Dive, You should show it to
your Diving Officer and insert it in your Qualification Record Logbook for reference purposes.
VALIDITY & STORAGE
All Divers need to submit a completed medical questionnaire annually. If there are any “yes” responses, the medical referee will decide on fitness
to dive, any change in health must be declared to a referee. Once a “yes” has been cleared as fit to dive and there are no new changes in health, the
medical questionnaire will be passed in subsequent years with no further medical needed. A copy of completed form must be kept by the diver,
his/her Branch and a copy sent to the organisations HQ. The Medical Referee is advised to retain the records of those examined. and give a
photocopy of the record to the diver and send a copy to organisations HQ.

SECTION A
This portion to be completed by the applicant

Dive Organisation………………Branch. .………………………….Postcode. Date of birth.Mem. No.………………. Diver Medical Health Questionnaire
1. Have you suffered at any time from diseases of the heart and 11. Have you ever had any other disease of the brain or circulation including high blood pressure, angina, chest pains nervous system (including strokes or multiple sclerosis)? 2. Have you suffered from or had to take medication for asthma? 12. Have you ever had any back or spinal surgery? 3. Have you at any time had chest or heart surgery? 13. Have you any history of mental or psychological illness of any kind, fear of small spaces, crowds or panic attacks? 4. Have you ever had collapsed lung or pneumothorax? 14. Have you any history of alcohol or drug abuse in the past 5. Have you ever had any other chest or lung disease? 6. Have you suffered at any time from blackouts, fainting or 16. Are you currently taking any prescribed medication 7. Have you had regular ear problems in the past ten years? 17. Are you currently receiving medical care or have you consulted the doctor in the last year other than for trivial 8. Do you have an ileostomy, colostomy or ever had repair of a 18. Have you ever been refused a diving medical certificate or life insurance or been offered special terms? 19. Have you ever had, or been treated for, decompression If you answered “Yes” to any question, then give further details below. The completed form should then be returned to headquarters and they will forward it to a medical referee. I hereby declare that to the best of my knowledge, l am in good general health and declare that I have not omitted any information which might be relevant to my fitness for diving. I authorise any doctor who has attended me to disclose my medical history if requested to by a Medical Referee. Signed_________________________________________________________ Date_________________________________ MEDICAL STANDARDS
These notes are included for the guidance of divers completing this form who may be unfamiliar with requirements for diving. If in doubt, please discuss with your nearest Medical Referee. Should your health change, you must notify your diving organisation and see a Medical Referee. If your instructor is unhappy about any aspect of your health, you may be referred to a Medical Referee. If planning to dive abroad, some countries require a full medical examination. Check in good time before you travel. Diving is not advised during pregnancy or when trying to conceive. Smoking reduces fitness and increases the risk of air embolism, pneumothorax, and coronary thrombosis. DISQUALIFYING FACTORS
ALLOWABLE FACTORS
OTHER POINTS

Ear clearing is best checked by a practical test chronic vestibular disease in new entrants. Perforated eardrums can be surgically repaired "paper thin" scars. Unilateral nasal block. Sinusitis if not adversely affected by diving Oral Cavity
Dentures must be retained in place on fully opening the mouth and not be Bad teeth and fillings should not normally dislodged by placing jaws together in any position, or by movement of one denture disqualify from diving but dental attention is against the other. They should extend to the muco-buccal fold. If dentures do not recommended as neglect leads to dental caries, satisfy these requirements, they should not be worn whilst diving. Cleft palate not Respiratory System
A chest X-ray is not required on entry or at Tuberculosis scars other than healed primary repeat medical examination unless there is a
history of significant cardiovascular disease, respiratory disease or occupational exposure (since the last medical in the case of a repeat surgical treatment should be discussed with a medical) or if the physical examination reveals pneumothorax that occurred more than four respiratory systems. Doctors must see film or years ago may be allowable provided a full set of lung function tests are performed and are normal. A Medical Referee must be consulted. Cardiovascular System
Subjects with a pacemaker must be seen by a disease), significant valve disease. Other heart disease, systolic pressure over 160 mm Hg, diastolic pressure over 100 mm Hg in entrants, or other evidence of hypertensive Intracardiac shunts (“Holes in the heart”) must be seen by a Medical Referee. Haematology
Haemophilia if factor VIII is below 20%, Sickle cell test only where clinically indicated. polycythaemia are not allowed to dive except provided factor VIII is more than 20% but only Subjects with sickle cell trait should exercise caution when using rebreathers owing to the risks associated with mild degrees of hypoxia. Polycythaemia if haematocrit normal with treatment. Abdomen and
Significant proteinuria (albumin in the urine), Urogenital System
Nervous System and
History of confirmed epilepsy including post- A single isolated fit or severe head injury to be impairment to be reported to Referee. A long Any serious head injury in past three months. fit free period off anticonvulsants may be personality disorders. Any disease of CNS (MS, Polio, Petit Mal, etc.) to be seen by Medical Referee. Endocrine
An annual medical is mandatory for diabetics. The use of the following disqualifies: oral sympathomimetics (other than proprietary tranquillisers, sedatives and hypnotics) has been nasal decongestants), oral steroids, muscle used, the candidate should not dive for at least 3 relaxants, digoxin, and psychotropic drugs - months after complete cessation of therapy without the consent of a Medical Referee. Alcohol, drug or narcotic abuse to disqualify. Decompression illness
since last Medical
Disabilities
Anyone with a significant disability must be assessed by a Medical Referee. Suitable organisations to contact are "Dolphin" (Tel No 01752 209999) or the Headquarters of the Diving Associations who have jointly published this form.

Source: http://www.musac.co.uk/Downloads/Application-for-Renewed-Membership%202010.pdf

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