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Certified Continued Education Course Waiver








Continue your scuba journey and experience new adventures with a PADI Instructor by your side. Fine-tune your buoyancy skills, build confidence in your navigation abilities, and try new activities like underwater videography, swimming like a mermaid or choose to improve your knowledge about sharks, corals and turtles to name just a few of the Specialty Courses.

To participate in this course you will need to provide acceptable proof of certification by presenting a physical card, digital card (eCard on your phone) or an image of your physical card at check-in. Please note that a signed logbook does not provide proof of dive certification. Without evidence of certification at check-in, you will not be able to join the dive and will be charged in full.

The cost of a Continued Education Course will vary depending on individual course plus $56.20 for the certification card. The cost will include all scuba equipment for ocean dives unless arranged otherwise. For Continued Education Courses requiring eLearning, I acknowledge that I will complete all eLearning prior to the start of the course. I understand that the eLearning will be with PADI. Certification cards may be withheld until payment has been received by the dive shop from the activity center you paid your monies to.

Customer(s) wishing to cancel or reschedule activity must provide 72 hours notice to Maui Diving Scuba & Snorkel Center. NO REFUNDS WILL BE GIVEN FOR CANCELLATIONS BY CUSTOMER WITH LESS THAN 72 HOURS NOTICE OR WHEN ALTERNATE SITES ARE SELECTED OR FOR ANY OTHER REASON, SUCH AS WEATHER, EAR TROUBLE, ILLNESS OR SEASICKNESS; BEFORE, DURING OR AFTER DIVING! Customer has been informed that a medical form will follow. Failure of completion for reasons on the medical form within 72 hours does not constitute a refund.

BY INITIALING THIS I UNDERSTAND ALL OF THE ABOVE CONTENTS.


December 21, 2024


By signing this waiver, I understand that I have purchased an activity or service. I understand this contract supersedes all previous contracts and agreements with my credit card company and I personally guarantee payment in cash, or credit card to vendor MAUI DIVING SCUBA & SNORKEL CENTER Activity Centers known or unknown vendors ETC.

Please read carefully, fill in all blanks and agree to each paragraph before signing. 

1. I acknowledge that I am a certified scuba diver trained in safe diving practices. I will provide acceptable proof of certification by presenting a physical card, digital card (eCard on my phone) or an image of my physical card at check-in. I understand that a signed logbook does not provide proof of dive certification. Without evidence of certification at check-in, I acknowledge that I will not be able to join the dive and will be charged in full. 

2. I hereby affirm that I have been advised and thoroughly informed of the inherent hazards of skin and scuba diving. 

3. I further agree that under no circumstance will I make, prosecute or present any claim against those entities identified above for any act, omission or due to their negligence either passive or active relating to such activities or from the ownership, maintenance, use operation or control of any automobile, shop, boat, hotel, vehicle common carrier, or otherwise. It is my intention by signing this document to exempt and release those entities identified above and their agents, servants, contractors and employees from liability for personal injury, property damage, wrongful death and loss of services whether caused by negligence either passive or active or otherwise. By signing this document, I acknowledge that I assume all risk of personal injury, property damage, wrongful death or loss of services upon myself.

4. I further state; I will not fly in an airplane or go to Haleakala Crater (volcano 10, 023 ft.) within 12 or 18 hours after my last dive or exceed 1,000 feet in elevation during this scuba diving class. I understand that drinking alcohol directly after diving may cause decompression sickness.

5. I understand that the terms herein are contractual and not a mere recital, and that I have signed this document of my own free act. I also understand by not initialing or signing any part of this waiver will be construed as I am doing so with full intent and knowledge to defraud these contract(s) and can be held responsible for fraud or terminated from this diving program at any time with no refund.

Standard Safe Diving Practices Statement of Understanding

This is a statement in which you are informed of the established safe diving practices for skin and scuba diving. These practices have been compiled for your review and acknowledgement and are intended to increase your comfort and safety in diving. Your signature on this statement is required as proof that you are aware of these safe diving practices. Read and discuss the statement prior to signing it. If you are a minor, this form must also be signed by a parent or guardian.

This is also a release of your right to sue Maui Diving Scuba & Snorkel Center and its employees, contractors, agents and assigns for personal injuries of wrongful death that may occur during the forthcoming dive activity as a result of the inherent risks associated with scuba diving/snorkeling or as a result of negligence, passive or active. I agree to all Lines 1-11.

I understand that as a diver I should:

1. Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and refresh myself on important information. 

2. Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which I am experienced, postpone diving or select an alternate site with better conditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave or technical diving unless specifically trained to do so. 

3. Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correct fit and function prior to each dive. Have a buoyancy control device, low-pressure buoyancy control inflation system, submersible pressure gauge and alternate air source and dive planning/monitoring device (dive computer, RDP/dive tables—whichever you are trained to use) when scuba diving. Deny use of my equipment to uncertified divers. 

4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recognize that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed six months. 

5. Adhere to the buddy system throughout every dive. Plan dives – including communications, procedures for reuniting in case of separation and emergency procedures – with my buddy. 

6. Be proficient in dive planning (dive computer or dive table use). Make all dives no decompression dives and allow a margin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 metres/60 feet per minute. Be a SAFE diver – Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer. 

7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving. Carry at least one surface signaling device (such as signal tube, whistle, mirror). 

8. Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessive hyperventilation when breath-hold diving. Avoid overexertion while in and underwater and dive within my limitations. 

9. Use a boat, float or other surface support station, whenever feasible. 

10. Know and obey local dive laws and regulations, including fish and game and dive flag laws. 

11. I understand the importance and purposes of these established practices. I recognize they are for my own safety and well-being, and that failure to adhere to them can place me in jeopardy when diving. 

Liability Release and Assumption of Risk Agreement

I, by this instrument do exempt and release my instructor(s), the facility through which I received my instruction, Maui Diving Scuba & Snorkel Center, PADI and ALL RELATED ENTITIES AS DEFINED OR UNDEFINED, from all liability or responsibility whatsoever for personal injury, property damage or wrongful death however caused. Including but not limited to negligence, whether passive or active and shall include released parties. I have fully informed myself of the contents of this liability release and express assumption of risk by reading it before I signed it on behalf of my heirs and myself. I further acknowledge I will be financially responsible with respect to payment for services rendered by entities. Maui Diving Scuba & Snorkel Center all activity centers unknown but inclusive of payment. I personally guarantee payment by credit card, check, travelers check for activity regardless of locations, weather, ear trouble, seasickness or any other factors, which might arise before, during or after diving. By signing this release. I have purchased an activity or service and understand no refunds will be considered whatsoever. I understand this contract supersedes any and all previous agreements I have with my credit card company.

I understand and agree that PADI Members (“Members”), including Maui Diving Scuba & Snorkel Center and/or any individual PADI Instructors and Divemasters associated with the program in which I am participating, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of PADI Americas, Inc, or its parent, subsidiary and affiliated corporations (“PADI”). I further understand that Member business activities are independent, and are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver training programs, it is not responsible for, nor does it have the right to control, the operation of the Members’ business activities and the day-to-day conduct of PADI programs and supervision of divers by the Members or their associated staff. I further understand and agree on behalf of myself, my heirs and my estate that in the event of an injury or death during this activity, neither I nor my estate shall seek to hold PADI liable for the actions, inactions or negligence of Maui Diving Scuba & Snorkel Center and/or the instructors and divemasters associated with the activity.

I hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. I understand that diving with compressed air involves certain inherent risks; including but not limited to decompression sickness, embolism or other hyperbaric/air expansion injury that require treatment in a recompression chamber. I further understand that diving trips, as well as the open water diving trips which are necessary for training and for certification may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with such trips and instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site. 

I understand this Liability Release and Assumption of Risk Agreement (Agreement) hereby encompasses and applies to all diver training activities and courses in which I choose to participate. These activities and courses may include, but are not limited to, altitude, boat, cavern, AWARE, deep enriched air, photography/videography, diver propulsion vehicle, drift, dry suit, ice, multilevel, night, peak performance buoyancy, search & recovery, rebreather, underwater naturalist, navigator, wreck, adventure diver, rescue diver and other distinctive specialities (hereinafter "Programs").

I understand and agree that neither my instructor(s) the facility through which I receive my instruction, Maui Diving Scuba & Snorkel Center #18786 , nor PADI Americas, Inc., nor its affiliate and subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns (hereinafter referred to as “Released Parties”) may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occurs a result of my participation in this diving trip or program or as a result of the negligence of any party, including the Released Parties, whether passive or active.

In consideration of being allowed to participate in this diving trip or course (and optional Adventure Dive), hereinafter referred to as “program,” I hereby personally assume all risks of this program, whether foreseen or unforeseen, that may befall me while I am a participant in this program including, but not limited to, the academics, confined water and/or open water activities.

I further release, exempt and hold harmless said program and Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my enrollment and participation in this trip or program including both claims arising during the trip or program or after I receive my certification.

I also understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this trip or program, and that if I am injured as a result of heart attack, panic, hyperventilation, drowning or any other cause, that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same.

I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. I understand the terms herein are contractual and not a mere recital, and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid, that provision shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable provision had never been contained herein.

I hereby state and agree this Agreement will be effective for all activities associated with the Programs in which I participate.

I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns, or beneficiaries may have to sue the Released Parties resulting from my death. I further represent that I have the authority to do so and that my heirs, assigns, or beneficiaries will be stopped from claiming otherwise because of my representations to the Released Parties.

I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND ACKNOWLEDGMENT AGREEMENT BY READING IT BEFORE I SIGNED IT ON BEHALF OF MYSELF AND MY HEIRS.

I HAVE COMPLETED THE ATTACHED DIVER MEDICAL FORM (10346) AND I AFFIRM IT IS MY RESPONSIBILITY TO INFORM MY INSTRUCTOR OF ANY AND ALL CHANGES TO MEDICAL HISTOY AT ANY TIME DURING MY PARTICIPATION IN SCUBA PROGRAMS. I AGREE TO ACCEPT RESPONSIBILITY FOR OMISSIONS REGARDING MY FAILURE TO DISCLOSE ANY EXISTING OR PAST HEALTH CONDITION, OR ANY CHANGES THERETO.

I, BY THIS INSTRUMENT DO EXEMPT AND RELEASE MAUI DIVING SCUBA & SNORKEL CENTER AND ALL RELATED ENTITIES AS DEFINED ABOVE FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY. PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, INCLUDING, BUT NOT LIMITED TO, THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER BY NEGLIGENCE. PASSIVE OR ACTIVE.

I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS INFORMATION AND RELEASE BY READING IT BEFORE I SIGNED IT ON BEHALF OF MYSELF, MY FAMILY, HEIRS, ESTATE. AND/OR ASSIGNS. BY SIGNING THIS RELEASE FORM, I UNDERSTAND THAT I HAVE PURCHASED ACTIVITY OR SERVICE. I UNDERSTAND THIS CONTRACT SUPERSEDES ALL PREVIOUS CONTRACTS AND AGREEMENTS WITH MY CREDIT CARD COMPANY AND I PERSONALLY GUARANTEE PAYMENT, CREDIT CARD. CHECK TO VENDOR.

BY INITIALING THIS I UNDERSTAND ALL OF THE ABOVE CONTENTS.


December 21, 2024














First Diver's Name

First Name*

Middle Name

Last Name*

Phone*
First Diver's Date of Birth*
First Diver's Signature*
Second Diver's Name

First Name*

Middle Name

Last Name*
Second Diver's Date of Birth*
Third Diver's Name

First Name*

Middle Name

Last Name*
Third Diver's Date of Birth*
Fourth Diver's Name

First Name*

Middle Name

Last Name*
Fourth Diver's Date of Birth*
Fifth Diver's Name

First Name*

Middle Name

Last Name*
Fifth Diver's Date of Birth*
Sixth Diver's Name

First Name*

Middle Name

Last Name*
Sixth Diver's Date of Birth*
Seventh Diver's Name

First Name*

Middle Name

Last Name*
Seventh Diver's Date of Birth*
Eighth Diver's Name

First Name*

Middle Name

Last Name*
Eighth Diver's Date of Birth*
Ninth Diver's Name

First Name*

Middle Name

Last Name*
Ninth Diver's Date of Birth*
Tenth Diver's Name

First Name*

Middle Name

Last Name*
Tenth Diver's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check this box if you would like to be on our mailing list for news and information.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Proof of Certification
I understand that I must provide proof of certification in order to take this course. I agree and will do the following. *
I will provide my proof of certification by uploading to this waiver an image of my certification displaying my name, photo, certifying agency and diver number.
Please upload an image of your proof of certification here.
  
Image to include your name, photo, certifying agency and diver number. *
Valid file types: JPG, GIF, PNG, and PDF
2022 PADI Diver Medical Participant Questionnaire

To the Participant:

The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.

This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by Maui Diving Scuba & Snorkel Center located in the city of Lahaina, state of Hawaii.

Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent or guardian.

Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When established safety procedures are not followed, however, there are increased risks. To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely.

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. You can download the Diver Medical | Participant Questionnaire form online to take to your physician for a medical evaluation. The form is located at https://www.uhms.org/images/Recreational-Diving-Medical-Screening-System/forms/Diver_Medical_Participant_Questionnaire_10346_EN_English_2022-02-01.pdf

PADI medical form online and page two will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver's Physical Examination to take to your physician. The physician providing medical clearance cannot be the student.

Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and/or dive activities. References to "diving" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly. 

Note to Women: If you are pregnant, or attempting to become pregnant DO NOT DIVE.



Please answer these 10 questions. If you have to answer YES to one of them, please scroll down to the additional questions in the appropriately labeled section.
1. I have had problems with my lungs, breathing, heart and/or blood affecting my normal physical or mental performance. *
Yes (Go to Box A)
No
2. I am over 45 years of age. *
Yes (Go to Box B)
No
3. I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months. *
Yes*
No
4. I have had problems with my eyes, ears, or nasal passages/sinuses. *
Yes (Go to Box C)
No
5. I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. *
Yes*
No
6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. *
Yes (Go to Box D)
No
7. I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability. *
Yes (Go to Box E)
No
8. I have had back problems, hernia, ulcers, or diabetes. *
Yes (Go to Box F)
No
9. I have had stomach or intestine problems, including recent diarrhea. *
Yes (Go to Box G)
No
10. I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam). *
Yes*
No

If you answered NO to all 10 questions above a medical evaluation is not required. 

Please read and agree to the participant statement below by signing and dating it.

Participant Statement: I have answered all questions honestly, and 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. 



* If you answered YES to questions 3, 5 or 10 above OR to any of the subsequent questions in the boxes below, please read and agree to the statement above by signing and dating it AND take all three pages of the Diver Medical | Participant Questionnaire form to your physician for a medical evaluation. You can download the Diver Medical | Participant Questionnaire form online. The form is located at https://www.uhms.org/images/Recreational-Diving-Medical-Screening-System/forms/Diver_Medical_Participant_Questionnaire_10346_EN_English_2022-02-01.pdf Participation in a diving course requires your physician's approval. 







Today's Date *

By Entering Your Name here you are digitally signing that you understand the above Participant Statement *
Box A - I Have/Have had:

Only answer these questions if you've said yes to Question 1 above.

Chest surgery, heart surgery, heart valve surgery, an implantable medical device (e.g., stent, pacemaker, neurostimulator) or a pneumothorax (collapsed lung).
Yes
No
Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity/exercise.
Yes
No
A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.
Yes
No
Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.
Yes
No
Symptoms affecting my lungs, breathing, heart and/or blood in the last 30 days that impair my physical or mental performance.
Yes
No
Box B - I am over 45 years of age AND:

Only answer these questions if you said YES to Question 2 above.

I currently smoke or inhale nicotine by other means.
Yes
No
I have a high cholesterol level.
Yes
No
I have high blood pressure.
Yes
No
I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).
Yes
No
Box C - I have/have had:

Only answer these questions if you said YES to Question 4 above.

Sinus surgery within the last 6 months.
Yes
No
Ear disease or ear surgery, hearing loss, or problems with balance.
Yes
No
Recurrent sinusitis within the past 12 months.
Yes
No
Eye surgery within the past 3 months.
Yes
No
Box D - I have/have had:

Only answer these questions if you said YES to Question 6 above.

Head injury with loss of consciousness within the past 5 years.
Yes
No
Persistent neurologic injury or disease.
Yes
No
Recurring migraine headaches within the past 12 months, or take medications to prevent them.
Yes
No
Blackouts or fainting (full/partial loss of consciousness) within the last 5 years.
Yes
No
Epilepsy, seizures, or convulsions, OR take medications to prevent them.
Yes
No
Box E - I have/have had:

Only answer these questions if you said YES to Question 7.

Behavioral health, mental or psychological problems requiring medical/psychiatric treatment.
Yes
No
Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication/psychiatric treatment.
Yes
No
Been diagnosed with a mental health condition or a learning/developmental disorder that requires ongoing care or special accommodation.
Yes
No
An addiction to drugs or alcohol requiring treatment within the last 5 years.
Yes
No
Box F - I have/have had:

Only answer these questions if you said YES to Question 8.

Recurrent back problems in the last 6 months that limit my everyday activity.
Yes
No
Back or spinal surgery within the last 12 months.
Yes
No
Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.
Yes
No
An uncorrected hernia that limits my physical abilities.
Yes
No
Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.
Yes
No
Box G - I have had:

Only answer these questions if you said YES to Question 9.

Ostomy surgery and do not have medical clearance to swim or engage in physical activity.
Yes
No
Dehydration requiring medical intervention within the last 7 days.
Yes
No
Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.
Yes
No
Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).
Yes
No
Active or uncontrolled ulcerative colitis or Crohn's disease.
Yes
No
Bariatric surgery within the last 12 months.
Yes
No
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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