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STUDENT REGISTRATION PACKET

Open Water Scuba Diver Certification Release

I understand and agree to the following:

1. I will attend the required class sessions and the required # pool sessions of the Open Water SCUBA course to begin on date and cost agreed upon.

2. The following SCUBA quality equipment is necessary: mask, snorkel, fins, booties, online code, slate, whistle, and logbook must be -purchased. Regulator, BCD, tanks & computer will be provided during the course. Additional equipment may be purchased or rented such as: wetsuit, knife and compass. 

3. After successful completion of any of the above courses, a series of open water dives are required to become certified. Local dives and group trips are available at an additional cost.

4. Important information is included in every class, pool and open water session. You must attend every session or your training will be incomplete. You will need to successfully complete a final evaluation in order to be certified as a scuba diver. The instructor, at his discretion, must make final judgment as to my competency to be a safe diver and be awarded certification.

5. I understand that there is a $35 nonrefundable registration fee included in the cost of this course. I also understand that if I cancel for any reason, the $35 registration fee in not refundable. Additionally, if I cancel in less than 7 days before the first session, 50% of the course cost is nonrefundable; after the first session, none of the course is refundable.

6. I understand that if I make any changes to my schedule less than 7 days before the scheduled date there will be a $55 fee to reschedule. There is a fee of $55 for any missed or required makeup, class or pool dives. If additional training is needed at any stage of the certification process, additional classes / clinics are available at an additional cost.

7. It is important to move to each step of the diving course in a timely manner so the previous step is fresh in your mind. Academic review must be done within 60 days of picking up the online code. Pool sessions must be completed within 60 days of academic review. A $35 refresher will be required for those going beyond the 60 day period.

8. For your safety and ours, SCUBA Network reserves the right to inspect all equipment you will be using in the pool or during open water dives PRIOR to starting any classes. At the sole discretion of SCUBA Network, any equipment deemed unsatisfactory or unfamiliar will not be allowed to be used. I understand that by not having equipment checked prior to the class sessions I may be turned away and be required to take the session at an additional fee.

I HAVE READ THIS AGREEMENT, I UNDERSTAND IT, I AGREE TO BE BOUND BY IT.


General Liability Release and Express Assumption of Risk

For ALL courses/specialty training programs under sanction through PADI, SDI/TDI, NAUI, HSA or DAN: 

Please read carefully, fill in all blanks and initial each paragraph before signing at bottom.

I hereby affirm that I have been advised and thoroughly informed of the inherent hazards of Scuba diving activities. 

I Agree

Further, I understand that diving with compressed air or oxygen enriched air (nitrox) involves certain inherent risks including decompression sickness, embolism, oxygen toxicity, inert gas narcosis, marine life injuries or other barotraumas/hyperbaric injuries can occur that require treatment in a recompression chamber. I further understand that the open water diving trips, which are necessary for training and certification, may be conducted at a site that is remote, either by time of distance or both from such a recompression chamber. I still choose to proceed with such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site.

I understand and agree that neither my Instructor(s), whether SCUBA Network, freelance, independent, or any affiliated instructors, the facility through which I received my instruction, SCUBA NETWORK, SCUBA DIVERS, INC; SCUBA Network Stores Inc. D/B/A SCUBA Network, its Franchisees, Employees or agents and/or its affiliated instructors, International Training, SDI, TDI and SCUBA Diving International, NAUI, PADI, nor the officers, directors, shareholders, affiliated companies, employees, agents, or assigns of the above listed entities and/or individuals, nor the authors of any materials including texts and tables expressly used for training and certification (hereinafter referred to as “Released Parties”) may be held liable or responsible in any way for any injury, death, or other damages to me or my family, heirs, or assigns that my occur as a result of my participation in this diving class or as a result of the negligence of any party, including the Released Parties, whether passive or active.

In consideration of being allowed to enroll in this course, I hereby personally assume all risks in connections with said course, for any harm, injury, or damage that may befall me while I am enrolled as a student of this course, including all risks connected therewith, whether foreseen or unforeseen.

I further agree to save, defend, indemnify, and hold harmless said course and Released Parties from any claim or lawsuit by me, anyone purporting to act on my behalf, my family, estate, heirs or assigns, arising directly or indirectly out of my enrollment and participation in this course including both claims arising during the course or after I receive my certification even if such claims may be groundless, false or fraudulent.

I also understand that diving activities are physically strenuous and that I will be exerting myself during this diving course, and that if I am injured as a result of heart attached, panic, hyperventilation, oxygen toxicity, inert gas narcosis, drowning, etc. that I expressly assume the risk of said injuries and that I will not hold the above listed individuals or companies responsible for the same, and I agree to defend, indemnify, and hold harmless said course and Released Parties for any such injuries incurred by me.

I understand that these activities may place me deeper than I am able to safely execute a free (without breathing gas) ascent from.

I understand that I may be required to furnish my own equipment and that I am responsible for its operating condition and maintenance.

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 that the terms herein are contractual and not a mere recital and that I have signed this document of my own free act. Further that I understand and agree that, in the event that one or more of the provisions of this agreement, for any reason, is held by a court of competent jurisdiction to be invalid or unenforceable in any respect, such invalidity, illegality or unenforceability shall not affect any other provision hereof, and this agreement shall be construed as if such invalid, illegal or unenforceable provision or provisions had never been contained herein.

Non-Agency Disclosure and Acknowledgment Agreement

I understand and agree that PADI Members (“Members”), including and/or any individual PADI Instructors and Dive masters 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 Scuba Network and/or the instructors and dive masters associated with the activity.

IT IS THE INTENTION OF ALL PEOPLE ON THIS WAIVER BY THIS INSTRUMENT TO EXEMPT AND RELEASE MY INSTRUCTORS, SCUBA NETWORK AND ALL OTHER RELATED ENTITIES AND RELEASED PARTIES AS DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, OR ARISING OUT OF, DIRECTLY OR INDIRECTLY, INCLUDING, BUT NOT LIMTED TO, THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE. I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS LIABILITY RELEASE AND EXPRESS ASSUMPTION OF RISK BY READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF AND MY HEIRES.

This document is required for all courses and specialties. No alteration, changes, omissions or revisions may be made.



e-Learning Access Codes & Certification Cards

Special note: When purchasing an e-Learning academic training code, once you have left SCUBA Network, the online code is NON-REFUNDABLE, nor EXCHANGEABLE. All e-Learning code sales are final and are good for one year from the date of purchase before expiration. If the e-Learning code expires, the code will no longer be accessible and a new code will need to be purchased.

 

VIDEO/PHOTOGRAPH RELEASE

I hereby grant SCUBA Network, the irrevocable right and permission to use photographs and/or video recordings of me on Company social media, websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.

I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed. Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof. and all plates, negatives, recording tape and digital files are and shall remain the property of SCUBA Network.

I hereby release, acquit and forever discharge SCUBA Network, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings. including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.


Medical History Information Form

MEDICAL HISTORY STATEMENT: I understand that skin and SCUBA diving are strenuous activities involving significant pressure changes and that normal, healthy heart, lungs, ear and sinus, are essential prerequisites for my safety and well-being. I hereby confirm that to the best of my knowledge my circulatory and respiratory systems and body air spaces are healthy and normal and that I have no severe emotional or neurological problems or communicable diseases. I understand that I need to seek unconditional approval for diving from a licensed physician if I am uncertain as to my physical fitness for the rigors of diving.

If at anytime during your dive training your medical condition changes, notify your Instructor immediately and complete a new medical history form for inclusion in your student file.


Today's Date: May 28, 2022



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Student Registration

COURSE*

ADDRESS

Street Address

Address Line 2

City

State

Zipcode

e-Learning and Certification Card Release


Salesperson at Sign-UP:

E-Learning Code Purchased:

Student Registration Information for C-Card Processing


Store Location:

Course:

Student Name (first/last):

D.O.B.

Medical Information

Attention Deficit or Impulse Control or other Behavioral Problems*
No
Yes
Claustrophobia*
No
Yes
Agoraphobia*
No
Yes
Epilepsy*
No
Yes
Ear Trauma or Hearing Issues*
No
Yes
Sinus or Hay Fever conditions*
No
Yes
High Blood Pressure*
No
Yes
Angina*
No
Yes
Heart Conditions and Surgery*
No
Yes
Bronchitis*
No
Yes
Asthma*
No
Yes
Tuberculosis*
No
Yes
Respiratory Problems*
No
Yes
Back Injury/Spinal Problems*
No
Yes
Diabetes*
No
Yes
Hernia*
No
Yes
Dizziness/Fainting*
No
Yes
Recent Surgery*
No
Yes
Hospitalized*
No
Yes
Pregnant*
No
Yes
Motion Sickness*
No
Yes
COVID (Current or Long term affect)*
No
Yes
Physical Disability*
No
Yes
Serious Injury*
No
Yes
Hepatitis*
No
Yes
HIV diagnosis*
No
Yes
Regular Medications*
No
Yes
Drug Allergies*
No
Yes
Alcohol or Drug Dependency *
No
Yes
PRIOR rejection for any activity/sport/training*
No
Yes
ANY MEDICAL CONDITION NOT LISTED ABOVE*
No
Yes

Explain in detail any and all of the issues you checked YES for: *

If you are over 45 of age answer yes/no to any of following: 

Current smoke:*
No
Yes
High Blood Pressure Medication/Diagnosis:*
No
Yes
High cholesterol levels:*
No
Yes
Are under medical care:*
No
Yes

Explain in detail anything you clicked "yes" to:

List all Medications you are presently taking:

You will need a medical note if any of the above questions are marked YES


certify that the above information is correct to the best of my knowledge.

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. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. 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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