{"id":3406,"date":"2025-07-25T10:55:20","date_gmt":"2025-07-25T08:55:20","guid":{"rendered":"https:\/\/diveacademy-santapola.es\/form-courses\/"},"modified":"2025-08-12T19:38:34","modified_gmt":"2025-08-12T17:38:34","slug":"form-courses","status":"publish","type":"page","link":"https:\/\/diveacademy-santapola.es\/en\/form-courses\/","title":{"rendered":"Form &#8211; Courses"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_3' style='display:none'><style>#gform_wrapper_3[data-form-index=\"0\"].gform-theme,[data-parent-form=\"3_0\"]{--gf-color-primary: 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Cursos<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/3406' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_1\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_1'>Date of the course<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_1' id='input_3_1' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_1_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_1_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_1' class='gform_hidden' value='https:\/\/diveacademy-santapola.es\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_4\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>  Personal information  <\/h2><\/div><fieldset id=\"field_3_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_5'>\n                            \n                            <span id='input_3_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_3_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_56\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_56'>E-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_56' id='input_3_56' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>DNI \/ NIE \/ Passport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_3_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Telephone (add country code)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_3_10' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_52\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_52'>Height<\/label><div class='ginput_container ginput_container_number'><input name='input_52' id='input_3_52' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_54\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_54'>Weight<\/label><div class='ginput_container ginput_container_number'><input name='input_54' id='input_3_54' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_55\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_55'>Foot size<\/label><div class='ginput_container ginput_container_number'><input name='input_55' id='input_3_55' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>\u00bfC\u00f3mo nos has conocido?<\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_3_14' class='large gfield_select'     aria-invalid=\"false\" ><option value='TripAdvisor' >TripAdvisor<\/option><option value='Internet' >Internet<\/option><option value='Walking' >Paseando<\/option><option value='For a friend' >Por un amigo<\/option><option value='Social networks' >Social networks<\/option><option value='Others' >Otros<\/option><\/select><\/div><\/div><fieldset id=\"field_3_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Want to receive news, updates and offers? We will add you to our mailing list <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_15'>\n\t\t\t<div class='gchoice gchoice_3_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_3_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_15_0' id='label_3_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_3_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_15_1' id='label_3_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_22\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Emergency contact<\/h2><\/div><fieldset id=\"field_3_17\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name and surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_17'>\n                            \n                            <span id='input_3_17_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.3' id='input_3_17_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_17_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_17_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.6' id='input_3_17_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_17_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_18\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>Telephone (add country code)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_3_18' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>Relaci\u00f3n con el contacto<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_21\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_21.1' id='input_3_21_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_21_1' >I agree with the <a href=\"https:\/\/www.diveacademy-santapola.es\/politica-de-privacidad\/\">privacy policy.<\/a><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_21.2' value='I agree with the &lt;a href=&quot;https:\/\/www.diveacademy-santapola.es\/politica-de-privacidad\/&quot;&gt;privacy policy.&lt;\/a&gt;' class='gform_hidden' \/><input type='hidden' name='input_21.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_3_50\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr>\n<h1>RECREATIONAL DIVING HEALTH STATUS QUESTIONNAIRE<\/h1>\n<p>Diving requires good physical and mental health. There are some medical conditions that can be dangerous while scuba diving, which are listed below. Those who have or are predisposed to any of these conditions should be evaluated by a physician. This Diver&#8217;s Physician Questionnaire provides a basis for determining whether you should seek such an evaluation. If you have any concerns about your diving fitness and they are not represented on this form, consult with your physician before diving.    <\/p>\n<p>References to &#8220;scuba diving&#8221; in this form cover both recreational scuba diving and freediving. This form is designed primarily as an initial medical examination for new divers, but is also appropriate for divers receiving continuing education. For your safety and the safety of others who may dive with you, answer all questions honestly.  <\/p>\n\n<h2>INSTRUCTIONS<\/h2>\n<p>Complete this questionnaire as a prerequisite for freediving or scuba training.<\/p>\n<p><strong>Note to women:<\/strong> If you are pregnant or trying to become pregnant, do not dive.<\/p>\n<\/div><fieldset id=\"field_3_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have had problems with my lungs or breathing, heart or blood.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_24'>\n\t\t\t<div class='gchoice gchoice_3_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_3_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_24_0' id='label_3_24_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_3_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_24_1' id='label_3_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Thoracic surgery, cardiac surgery, heart valve surgery, stent placement or pneumothorax (collapsed lung).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_57'>\n\t\t\t<div class='gchoice gchoice_3_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_3_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_57_0' id='label_3_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_3_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_57_1' id='label_3_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Asthma, wheezing, severe allergies, hay fever or congested airways in the past 12 months that limit my physical activity or exercise.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_58'>\n\t\t\t<div class='gchoice gchoice_3_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_3_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_58_0' id='label_3_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_3_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_58_1' id='label_3_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >A problem or disease involving my heart such as: angina pectoris, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy or stroke, or I am taking medication for any heart condition.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_59'>\n\t\t\t<div class='gchoice gchoice_3_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_3_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_59_0' id='label_3_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_3_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Recurrent bronchitis and persistent cough in the past 12 months, or have been diagnosed with emphysema.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_60'>\n\t\t\t<div class='gchoice gchoice_3_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_3_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_60_0' id='label_3_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_3_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_60_1' id='label_3_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tengo m\u00e1s de 45 a\u00f1os.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_25'>\n\t\t\t<div class='gchoice gchoice_3_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='S\u00ed'  id='choice_3_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_25_0' id='label_3_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_3_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_25_1' id='label_3_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I currently smoke or inhale nicotine by other means.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_61'>\n\t\t\t<div class='gchoice gchoice_3_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_3_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_61_0' id='label_3_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_3_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_61_1' id='label_3_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have a high cholesterol level.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_62'>\n\t\t\t<div class='gchoice gchoice_3_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_3_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_62_0' id='label_3_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_3_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_62_1' id='label_3_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have high blood pressure.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_63'>\n\t\t\t<div class='gchoice gchoice_3_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_3_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_63_0' id='label_3_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_3_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_63_1' id='label_3_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have had a family member (1st or 2nd degree of consanguinity) who died of sudden death or of heart disease or stroke before age 50, or I have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_64'>\n\t\t\t<div class='gchoice gchoice_3_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_3_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_64_0' id='label_3_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_3_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_64_1' id='label_3_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Me cuesta realizar ejercicio moderado (por ejemplo, caminar 1,6 km en 12 minutos o nadar 200 metros sin descansar), o no he podido participar en una actividad f\u00edsica normal debido a rezones de estado f\u00edsico o de salud en los \u00faltimos 12 meses.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_26'>\n\t\t\t<div class='gchoice gchoice_3_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_3_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_26_0' id='label_3_26_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_3_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_26_1' id='label_3_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have had problems with my eyes, ears or nostrils or sinuses.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_27'>\n\t\t\t<div class='gchoice gchoice_3_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_3_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_27_0' id='label_3_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_3_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sinus surgery in the last 6 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_65'>\n\t\t\t<div class='gchoice gchoice_3_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Yes'  id='choice_3_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_65_0' id='label_3_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_3_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_65_1' id='label_3_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Diseases of the ear or ear surgery, hearing loss or balance disorders.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_66'>\n\t\t\t<div class='gchoice gchoice_3_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_3_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_66_0' id='label_3_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_3_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_66_1' id='label_3_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Recurrent sinusitis in the last 12 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_67'>\n\t\t\t<div class='gchoice gchoice_3_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_3_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_67_0' id='label_3_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_3_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_67_1' id='label_3_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Ocular surgery in the last 3 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_68'>\n\t\t\t<div class='gchoice gchoice_3_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Yes'  id='choice_3_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_68_0' id='label_3_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_3_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_68_1' id='label_3_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have had surgery within the last 12 months or have ongoing problems related to a previous surgery.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_28'>\n\t\t\t<div class='gchoice gchoice_3_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='S\u00ed'  id='choice_3_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_28_0' id='label_3_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_3_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_28_1' id='label_3_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >He perdido el conocimiento, he tenido dolores de cabeza por migra\u00f1a, convulsiones, accidente cerebrovascular, lesi\u00f3n significativa en la cabeza o he sufrido de lesi\u00f3n o enfermedad neurol\u00f3gica persistente.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_29'>\n\t\t\t<div class='gchoice gchoice_3_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='S\u00ed'  id='choice_3_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_29_0' id='label_3_29_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_3_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_29_1' id='label_3_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Head injury with loss of consciousness within the last 5 years.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_69'>\n\t\t\t<div class='gchoice gchoice_3_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_3_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_69_0' id='label_3_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_3_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_69_1' id='label_3_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Persistent neurological injuries or diseases.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_70'>\n\t\t\t<div class='gchoice gchoice_3_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Yes'  id='choice_3_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_70_0' id='label_3_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_3_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_70_1' id='label_3_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Recurrent migraine headaches in the last 12 months, or I take medication to prevent them.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_71'>\n\t\t\t<div class='gchoice gchoice_3_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_3_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_71_0' id='label_3_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_3_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_71_1' id='label_3_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Fainting or blackouts (total\/partial loss of consciousness) in the last 5 years.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_72'>\n\t\t\t<div class='gchoice gchoice_3_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Yes'  id='choice_3_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_72_0' id='label_3_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='No'  id='choice_3_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_72_1' id='label_3_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Epilepsy, seizures or convulsions, or I take medication to prevent them.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_73'>\n\t\t\t<div class='gchoice gchoice_3_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Yes'  id='choice_3_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_73_0' id='label_3_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_3_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_73_1' id='label_3_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks or an addiction to drugs or alcohol.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_30'>\n\t\t\t<div class='gchoice gchoice_3_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_3_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_30_0' id='label_3_30_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_3_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_30_1' id='label_3_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Behavioral health, mental or psychological problems requiring medical or psychiatric treatment.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_74'>\n\t\t\t<div class='gchoice gchoice_3_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_3_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_74_0' id='label_3_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_3_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_74_1' id='label_3_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Major depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder requiring psychiatric medication\/treatment.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_75'>\n\t\t\t<div class='gchoice gchoice_3_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Yes'  id='choice_3_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_75_0' id='label_3_75_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='No'  id='choice_3_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_75_1' id='label_3_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have been diagnosed with a mental health condition or a learning or developmental disorder that requires ongoing care.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_76'>\n\t\t\t<div class='gchoice gchoice_3_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_3_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_76_0' id='label_3_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_3_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_76_1' id='label_3_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >A drug or alcohol addiction requiring treatment within the last 5 years.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_77'>\n\t\t\t<div class='gchoice gchoice_3_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_3_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_77_0' id='label_3_77_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_3_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_77_1' id='label_3_77_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >He tenido problemas de espalda, hernia, ulceras o diabetes.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_31'>\n\t\t\t<div class='gchoice gchoice_3_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='S\u00ed'  id='choice_3_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_0' id='label_3_31_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_3_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_1' id='label_3_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Recurrent back problems in the last 6 months that limit my daily activity.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_78'>\n\t\t\t<div class='gchoice gchoice_3_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_3_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_78_0' id='label_3_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_3_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_78_1' id='label_3_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Back or spine surgery in the last 12 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_79'>\n\t\t\t<div class='gchoice gchoice_3_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Yes'  id='choice_3_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_79_0' id='label_3_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='No'  id='choice_3_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_79_1' id='label_3_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Diabetes, whether controlled by insulin or diet, or gestational diabetes within the last 12 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_80'>\n\t\t\t<div class='gchoice gchoice_3_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_3_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_80_0' id='label_3_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_3_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_80_1' id='label_3_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >An uncorrected hernia that limits my physical abilities.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_81'>\n\t\t\t<div class='gchoice gchoice_3_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_3_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_81_0' id='label_3_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_3_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_81_1' id='label_3_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Active or untreated ulcers, problematic wounds or ulcer surgery within the last 6 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_82'>\n\t\t\t<div class='gchoice gchoice_3_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Yes'  id='choice_3_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_82_0' id='label_3_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No'  id='choice_3_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_82_1' id='label_3_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have had stomach or intestinal problems, including recent diarrhea.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_32'>\n\t\t\t<div class='gchoice gchoice_3_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_3_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_32_0' id='label_3_32_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_3_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_32_1' id='label_3_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I have ostomy surgery and am not medically cleared to swim or participate in physical activity.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_83'>\n\t\t\t<div class='gchoice gchoice_3_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_3_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_83_0' id='label_3_83_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_3_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_83_1' id='label_3_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Dehydration requiring medical intervention in the last 7 days.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_84'>\n\t\t\t<div class='gchoice gchoice_3_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_3_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_84_0' id='label_3_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_3_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_84_1' id='label_3_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_85'>\n\t\t\t<div class='gchoice gchoice_3_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Yes'  id='choice_3_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_85_0' id='label_3_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='No'  id='choice_3_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_85_1' id='label_3_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_86\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Frequent heartburn, regurgitation or gastroesophageal reflux disease (GERD).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_86'>\n\t\t\t<div class='gchoice gchoice_3_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Yes'  id='choice_3_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_86_0' id='label_3_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='No'  id='choice_3_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_86_1' id='label_3_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Active or uncontrolled ulcerative colitis or Crohn&#039;s disease.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_87'>\n\t\t\t<div class='gchoice gchoice_3_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Yes'  id='choice_3_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_87_0' id='label_3_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='No'  id='choice_3_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_87_1' id='label_3_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Bariatric surgery in the last 12 months.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_88'>\n\t\t\t<div class='gchoice gchoice_3_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Yes'  id='choice_3_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_88_0' id='label_3_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_3_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_88_1' id='label_3_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Estoy tomando medicamentos recetados (con la excepci\u00f3n de los anticonceptivos o los medicamentos antipal\u00fadicos).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_33'>\n\t\t\t<div class='gchoice gchoice_3_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_3_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_0' id='label_3_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_3_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_1' id='label_3_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Participant&#8217;s signature<\/h2>\n<p><strong>If you answered NO<\/strong> to all 10 questions above, a medical evaluation is not required. Please read and accept the participant statement below with the date and your full name. <\/p><\/div><fieldset id=\"field_3_35\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name and surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_35'>\n                            \n                            <span id='input_3_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_3_35_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_36\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_36' id='input_3_36' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_36_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_36_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_36' class='gform_hidden' value='https:\/\/diveacademy-santapola.es\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_37'>Today&#039;s date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_3_37' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_37_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_37_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_37' class='gform_hidden' value='https:\/\/diveacademy-santapola.es\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_38\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_38.1' id='input_3_38_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_38_1' >I have answered all questions honestly, and I understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_38.2' value='I have answered all questions honestly, and I understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.' class='gform_hidden' \/><input type='hidden' name='input_38.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_3_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>*If you<strong>answered YES<\/strong> to questions 3, 5 or 10 above or to any of the questions in boxes A, B, C, D, E, F AND G, read and accept the above statement with the date and your signature, and <strong>take the Medical Evaluation Form to your physician<\/strong> for a medical evaluation. Participation in a dive training program requires the evaluation and approval of your physician. <\/div><div id=\"field_3_43\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr>\n<h3>Declaraci\u00f3n de Riesgos y Responsabilidad\/ Divulgaci\u00f3n Ajena a la Agencia<\/h3>\n<h1>ENTRENAMIENTO DE CAR\u00c1CTER GENERAL<\/h1>\n<p><strong>Por favor, lea detenidamente este documento y rellene los espacios en blanco antes de firmarlo<\/strong><\/p>\n\n<h2>Divulgaci\u00f3n Ajena a la Agencia y Acuerdo de Reconocimiento<\/h2>\n<p>Comprendo y acepto que los Miembros PADI (&#8220;Miembros&#8221;), incluyendo <strong>DIVE ACADEMY SANTA POLA<\/strong> y\/o cualquier persona f\u00edsica PADI Instructors y Divemasters asociados al programa en el cual estoy participando est\u00e1n autorizados a utilizar las diversas Marcas Registradas de PADI y dirigir el entrenamiento PADI, sin embargo, no son agentes, empleados o franquiciados de PADI EMEA Ltd., PADI Americas, Inc., o sus subsidiarios o corporaciones afiliadas a (&#8220;PADI&#8221;).<\/p>\n<p>Asimismo, comprendo que las actividades comerciales de los Miembros son independientes, y no son propietarios ni est\u00e1n dirigidos por PADI, y que aunque PADI establece los est\u00e1ndares de los programas de buceo PADI, no es responsable de, ni tiene el derecho de controlar las operaciones de las actividades comerciales de los Miembros y la gesti\u00f3n diaria de los programas PADI y la supervisi\u00f3n de los buceadores por parte de los Miembros y de su personal asociado.<\/p>\n\n<h2>Declaraci\u00f3n de Riesgos y Responsabilidad<\/h2>\n<p>Esta es una declaraci\u00f3n por la cual a Ud. el buceador certificado se le informa de los riesgos del buceo en apnea y el buceo aut\u00f3nomo. La presente declaraci\u00f3n tambi\u00e9n establece las circunstancias en las que Ud. participa en la experiencia de buceo bajo su propio riesgo.<\/p>\n<p>Su firma en la presente declaraci\u00f3n es obligatoria como prueba de que la ha recibido y le\u00eddo. Es importante que lea el contenido de esta declaraci\u00f3n antes de firmarla. Si no entendiera alguna parte de la misma, por favor, com\u00e9nteselo a su instructor. Si fuera menor de edad, este formulario tambi\u00e9n lo debe firmar uno de sus padres o tutores.<\/p>\n\n<h2>Advertencia<\/h2>\n<p>El buceo en apnea y el buceo aut\u00f3nomo comportan riesgos inherentes que pueden dar lugar a lesiones graves o producir la muerte.<\/p>\n<p>Bucear con aire comprimido implica ciertos riesgos inherentes a ello: pueden producirse lesiones disb\u00e1ricas, embolias u otras lesiones hiperb\u00e1ricas que requieran tratamiento en una c\u00e1mara hiperb\u00e1rica. El entrenamiento y la obtenci\u00f3n del t\u00edtulo de buceador en aguas abiertas, puede implicar la necesidad de acometer viajes a lugares alejados, ya sea en el tiempo, en la distancia o en ambos, de una c\u00e1mara de descompresi\u00f3n. El buceo en apnea y el buceo aut\u00f3nomo son actividades f\u00edsicamente exigentes tal y como Ud. experimentar\u00e1 durante este programa de buceo. Tiene la obligaci\u00f3n de informar de su historial m\u00e9dico, de forma veraz y completa, a los profesionales de buceo y a las instalaciones donde tenga lugar este programa.\n<\/div><div id=\"field_3_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Aceptaci\u00f3n del Riesgo<\/h2><\/div><fieldset id=\"field_3_44\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_44.1' id='input_3_44_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_44_1' >Comprendo y acepto que, ni los profesionales de buceo que dirigen este programa, ni las instalaciones por medio de las cuales se dirige este programa, DIVE ACADEMY SANTA POLA, ni PADI EMEA Ltd., ni PADI Americas, Inc., ni sus afiliados o corporaciones subsidiarias, ni cualquiera de sus respectivos empleados, administrativos, agentes o cesionarios aceptan responsabilidad alguna por fallecimiento, lesi\u00f3n u otros da\u00f1os\/ p\u00e9rdidas que yo sufra en la medida que resulte de mi propia conducta o de cualquier cosa o situaci\u00f3n bajo mi control que implique mi propia negligencia.<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_44.2' value='Comprendo y acepto que, ni los profesionales de buceo que dirigen este programa, ni las instalaciones por medio de las cuales se dirige este programa, DIVE ACADEMY SANTA POLA, ni PADI EMEA Ltd., ni PADI Americas, Inc., ni sus afiliados o corporaciones subsidiarias, ni cualquiera de sus respectivos empleados, administrativos, agentes o cesionarios aceptan responsabilidad alguna por fallecimiento, lesi\u00f3n u otros da\u00f1os\/ p\u00e9rdidas que yo sufra en la medida que resulte de mi propia conducta o de cualquier cosa o situaci\u00f3n bajo mi control que implique mi propia negligencia.' class='gform_hidden' \/><input type='hidden' name='input_44.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_45\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_45.1' id='input_3_45_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_45_1' >Entiendo y acepto que cualquier p\u00e9rdida o rotura del material que me sea cedido por Dive Academy, ser\u00e1 mi completa responsabilidad y deber\u00e9 hacerme cargo de los costes de dicho material in situ al finalizar la actividad.<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_45.2' value='Entiendo y acepto que cualquier p\u00e9rdida o rotura del material que me sea cedido por Dive Academy, ser\u00e1 mi completa responsabilidad y deber\u00e9 hacerme cargo de los costes de dicho material in situ al finalizar la actividad.' class='gform_hidden' \/><input type='hidden' name='input_45.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_51\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_51.1' id='input_3_51_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_51_1' >In the absence of any negligence or other breach of duty on the part of the dive professionals conducting this program, the facilities through which this program is conducted, DIVE ACADEMY SANTA POLA, PADI EMEA Ltd., PADI Americas, Inc. and all involved parties referenced above, I understand that my participation in this dive program is entirely at my own risk and responsibility.<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_51.2' value='In the absence of any negligence or other breach of duty on the part of the dive professionals conducting this program, the facilities through which this program is conducted, DIVE ACADEMY SANTA POLA, PADI EMEA Ltd., PADI Americas, Inc. and all involved parties referenced above, I understand that my participation in this dive program is entirely at my own risk and responsibility.' class='gform_hidden' \/><input type='hidden' name='input_51.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_46\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_46.1' id='input_3_46_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_46_1' >I ACKNOWLEDGE RECEIPT OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGEMENT AGREEMENT AND STATEMENT OF RISKS AND LIABILITY AND ACKNOWLEDGE THAT I HAVE READ ALL TERMS PRIOR TO SIGNING SUCH STATEMENTS.<span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_46.2' value='I ACKNOWLEDGE RECEIPT OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGEMENT AGREEMENT AND STATEMENT OF RISKS AND LIABILITY AND ACKNOWLEDGE THAT I HAVE READ ALL TERMS PRIOR TO SIGNING SUCH STATEMENTS.' class='gform_hidden' \/><input type='hidden' name='input_46.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_3_47\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name and surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_47'>\n                            \n                            <span id='input_3_47_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.3' id='input_3_47_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_47_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_48\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_48'>Today&#039;s date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_48' id='input_3_48' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_48_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_48_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_48' class='gform_hidden' value='https:\/\/diveacademy-santapola.es\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_49\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full name of parent\/guardian (if applicable)<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_49'>\n                            \n                            <span id='input_3_49_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_49.3' id='input_3_49_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_49_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send to'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' 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