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Scuba Waiver and Medical Form

Your SSI Training Center will record your training progress. Upon successful completion of your SSI program, you will be issued an SSI Certification that is internationally recognized and available anywhere with internet access. Your SSI Training Forms will be maintained at your registered SSI Training Center. If you change your SSI Training Center, then you will need to complete a new set of Training Forms.

Download the free MySSI App, available for iOS or Android! SSI designed the MySSI App to be that “All-In-One Tool” for your diving experiences and to give you access to your Digital Learning Materials, Digital Logbook and Digital Certification Cards, all in the palm of your hand. There are a variety of features like news, local events, training dates, fun 360° videos and even dive tables and hand signals to review before your next dive.

 

OCEAN FIRST

COURSE TERMS AND CONDITIONS

Deposits & Payments: Every Ocean First, LLC (OF) course requires full payment for enrollment. Reservations are not guaranteed until payment is received. 

I Agree


Changes to Reservations: A $75 rescheduling fee will be charged for any scheduling change made fewer than 14 days prior to the first day of class.
I Agree


Cancellation & Refunds: Digital course materials are non-refundable and non-transferable. 

Cancellations made 14 days or more prior to the first day of class qualify for a full refund minus the cost of the digital materials. 

Cancellations made fewer than 14 days prior to the first day of class will incur a $75 cancellation fee per student.

I Agree

 

SSI Responsible Diver Code
Scuba diving is an adventure activity that requires the use of specialized life support equipment in an underwater environment where humans could not otherwise exist. As with other adventure activities, scuba diving has elements of risk that cannot be totally eliminated regardless of the amount of training, care, caution or expertise. SSI believes these risks may be reduced through the SSI Diver Diamond - development of proper Knowledge, Skills, Equipment and Experience. Ultimately it is up to each individual diver to assume the inherent risk associated with scuba diving and each diver’s responsibility to minimize the risk through exercising good judgment, common sense, respect and personal awareness during all diving activities. SSI has developed a Responsible Diver Code to remind divers of your responsibilities for each dive. 


As a Responsible Diver - I pledge to:
1. DIVE COMPETENTLY – Always dive within my training, certifi cation, experience, comfort and ability.
2. MAINTAIN APPROPRIATE DIVER HEALTH – Including appropriate fitness, physical health and mental awareness to dive.
3. UTILIZE A DIVE PLAN - Plan my dive and dive my plan. Listen to and follow dive briefings. 
4. BE A RESPONSIBLE DIVE PARTNER - Remain with my dive partner from start to finish of my dive. Know our plan to reunite if separated underwater.
5. INSPECT MY DIVE EQUIPMENT – Before each dive, I will inspect my equipment and make sure everything is working properly. I will confirm my cylinder valve is completely open. When using blended gas (i.e., Enriched Air Nitrox) – I shall analyze my gas and know its limitations. I will establish proper weighting, know how to release my weights, and verify my buoyancy compensator (BC) and inflator are connected and functioning properly. I will secure my submersible pressure/depth gauge and/or dive computer where it is easily accessible, and know how to use each.
6. DIVER AWARENESS – Monitor my cylinder pressure; making sure to surface with reserve gas and never run out of gas. Monitor my depth and time, respect no decompression limits, perform controlled ascents, safety stops, and monitor my dive partner.
7. MAINTAIN PROFICIENT SCUBA SKILLS – I understand scuba skills and knowledge are perishable. If it has been more than six months since my last dive, I understand the importance of taking a Scuba Skills Update course. I will maintain proper buoyancy throughout my dive, ascend slowly, and breathe properly to avoid overexpansion injuries. 
8. RESPECT THE ENVIRONMENT – Be aware of currents, waves, visibility, temperature, weather, boat traffi  c, slippery, uneven and unstable surfaces, overhead environments, entanglements, and hazardous marine life. I understand boats are unsteady surfaces and will always use one hand to stabilize myself. I understand the importance of taking an orientation dive with a local professional when diving in unfamiliar environments. I will obey all diving and applicable regulations, statutes and codes.
9. PLAN FOR EMERGENCIES – In addition to inspecting all of my dive equipment, I will verify my dive partner’s equipment is functioning properly, confi gured appropriately and that I know how to remove our weights in case of an emergency. I will make sure our alternate air sources are properly secured and easily accessible in case of a low air or out of air emergency. I will know scuba hand signals and how to alert others in case of an emergency. I will have an emergency action plan in case my dive partner or I have an emergency.
10. ACCEPT RESPONSIBILITY - I am ultimately responsible for my safety during all diving activities. Failure to comply with these responsibilities will increase my risk of serious injury or death. Accidents can happen even when all safety guidelines are followed, therefore I should obtain personal dive accident insurance. 

I understand the importance of being a responsible diver and I pledge to abide by the SSI Responsible Diver Code. I understand failure to abide by the SSI Responsible Diver Code will jeopardize my safety and well-being. 


Participant’s Signature

August 10, 2020

Date

SSI Recreational Scuba Training Assumption of Risk, Liability Release & Hold Harmless Agreement
This is a legal contract terminating your rights to file a lawsuit. Read carefully before signing. Warning – Scuba diving uses life-support equipment and techniques that have inherent risks which may cause serious injury, illness or death. In consideration of being allowed to participate in scuba training, I, the undersigned participant, expressly agree to be bound by this Agreement and comply with the SSI Responsible Scuba Diver Code. I understand this Agreement is between me, my family, estate, heirs and or anyone who may have a claim on my behalf; and OCEAN FIRST, LLC , including all instructors, facilities, boats, and training sites I receive training with or at; Scuba Schools International (“SSI”); and each of  their respective owners, officers, employees, representatives, volunteers, agents, contractors and any others on their behalves, whether specifically named or not (herein referred to as “Released Parties”). I voluntarily assume all risks of injury, illness and death, caused by scuba diving and all related activities, whether foreseeable or not, including but not limited to risks associated with: swimming, entering and exiting the water, falling on, struck by or abandoned by a boat, separation or lost underwater, holding my breath, pre-existing health conditions, heart failure, over-exertion, panic, drowning, pressure related injuries, decompression illness, environmental and marine life injuries, unknown causes, equipment malfunctions, improper dive planning, or improper action of other divers or support personnel (including failure to rescue, recover, resuscitate, or provide emergency assistance). I agree to waive, release, not sue, discharge, save, indemnify, and hold harmless the Released Parties of all claims, demands, causes of action, lawsuits and damages by me, my estate, family (including minor children), heirs, or others who may have a claim for my injury, illness or death as a result of any act or failure to act, including negligence by the Released Parties, associated with my scuba training and all related activities. I agree that it is my responsibility to inform my family and all those who may have legal rights on my behalf that I have entered into this Agreement and it is my intent that they be bound by this Agreement. I agree that me or my estate shall be fully liable (pay for) for the cost to the Released Parties for any claim brought on my behalf as a consequence of my participation in scuba diving and all related activities. I have carefully read, understand and agree to comply with the SSI Responsible Scuba Diver Code during all diving activities. I understand and agree that I am responsible for my own safety and well-being during all dive training and related activities. I am responsible for being physically, medically and mentally fit to participate in scuba diving. I affirm that all personal information I have provided on medical questionnaires is truthful and accurate to the best of my knowledge, and I will not hold others responsible or liable for any injury, illness or death caused by my failure to disclose a known medical condition. I am responsible for my own equipment configuration, assembly, and pre-dive inspection to verify it is appropriate and functioning properly. I am responsible for planning and performing all my dive activities, including anticipating potential emergencies. I will not hold anyone, including the Released Parties, responsible for failure to protect my well-being, ensure my proper use of equipment, or conduct my dive activities competently. I will not dive in conditions or at times that are not within my abilities and comfort level. If conditions become dangerous or I do not feel well or I become injured, I will immediate notify the dive leader and take action to correct the situation. I understand dive activities are conducted at sites that are remote, in time and distance, from medical care or a recompression chamber. I understand dive training does not guarantee my safety and that accidents happen even when proper procedures are followed. I understand the importance of, and my responsibility to have, personal insurance that specifically covers dive-related emergencies, emergency transportation, and medical treatments. I understand and agree that SSI licenses training centers, professionals and their affiliates to use various SSI trademarks and to conduct SSI approved training, but they are not agents, employees or franchisees of SSI, its parent, subsidiary, or affiliated corporations.  I further understand that SSI training centers, SSI professionals, and their affiliates’ businesses are independent, and are neither owned, operated, or controlled by SSI, and that while SSI establishes standards and materials for SSI training, it is not responsible for, nor does it have the right to control, the operation of the business activities or the day-to-day training and/or supervision of divers by SSI training centers, SSI professionals, their affiliated businesses, and/or their associated staff.  I further understand and agree on behalf of myself, that in the event of injury, illness or death during dive activities, I shall not hold SSI liable for the actions, inactions or negligence of the SSI training center, SSI professionals and other affiliated businesses or personnel associated with my dive activities. I have read this Agreement and the SSI Responsible Scuba Diver Code. I expressly understand my responsibilities and that I am giving up legal rights by signing this Agreement. I understand this is a legal contract and I am voluntarily signing it without duress or further inducement. I understand this is an unconditional and complete release of all liability to the greatest extent allowed by law. If any portion of this Agreement is found to be legally unenforceable or invalid, that portion shall be severed, and the remainder shall have full force and effect. I agree to be bound by this Agreement without modification of the preprinted text. The terms of this Agreement shall continue in effect for all scuba diving training (including entry-level training and continuing education training) and related activities for a period of one year from the date I signed this agreement. I am over 18 years of age and legally competent to engage in this Agreement, or I have acquired the written consent of my parent or guardian by completing a Youth Addendum form. 
 


Participant’s Signature

August 10, 2020

Date

Privacy Policy

This Privacy Policy explains why SSI Training Centers obtain your personal data for the purposes of conducting your training, issuing certifications, administration of your private information and any other necessary specifics regarding the performance of this agreement. We review this Privacy Policy periodically for compliance with changes to the GDPR (General Data Protection Regulation) and other relevant regulations. When necessary, we will update the Policy to comply with new requirements. SSI and SSI Training Centers jointly determine the purpose, scope and delivery of training content, processing, issuing and delivering certifications and administration of your personal data stored in the MySSI system at SSI International GmbH, Johann-Hoellfritsch-Straße 6, 90530 Wendelstein, Germany, Email: info@diveSSI.com, Tel:+49-9129-9099380.

If you have questions or you would like a copy of the Joint Controller Agreement which describes the arrangement above and the safeguards of protecting your personal data, go to the following link: https://my.divessi.com/ssi_dc_joint_controller_agreement, or contact SSI at privacy@diveSSI.com.

1. SSI Authorized Training Center “Data Controller” SSI Training Center Name:   Ocean First, LLC, 3015 Bluff Street, Boulder, Co 80301

 2. Personal Data “Personal data” is any information relating to an individual person (“data subject”). An identifiable natural person is one who can be identified, directly or indirectly, by reference to information such as a name, identification number, location data, or online identification. Name(s), address(es), telephone number(s), e-mail address(es), user ID(s), credit card number(s), social media account ID(s), login username(s), IP address(es) and GPS data are considered personal data.

3. Processing Your Personal Data SSI International GmbH, SSI Training Centers, your SSI Instructor and other SSI Professionals may all be involved in your training, processing, and delivery of your certification, therefore we need to collect and process the following personal data: • First and Last Name • Address, Post Box • Postcode, City • State, Country • Email Address • Telephone Numbers (optional) • Date of Birth • Gender • Photo • Language • SSI Master ID • Course Type, Course Progress • Certification Data (Number, Date, Instructor, Instructor Number, Number of Certification Dives, Certification Year) • Training Center Affiliation • MySSI App Geo Locations • Medical Information • Insurance Data (when applicable) • SSI Professional Number (only for SSI Professionals) • Quality Assurance Data (for Professionals) NOTE: The personal data we collect is for the sole purpose of delivering training content, processing, issuing and delivering certifications, and administration of your personal data stored in the MySSI system. With your registration in the MySSI system, you will be able to access everything SSI – Digital Training Materials, Digital DiveLog, Certification Cards and more at the SSI website www.divessi.com or on the MySSI mobile app. Additionally, SSI International GmbH (SSI), your SSI Training Center, SSI Instructors and SSI Professionals will have access to your personal data for training and certification purposes. For more information you may go to the SSI Privacy Policy at https://my.divessi.com/myssi_privacy. Here you will learn more about data processing, MySSI, the associated services provided by SSI and how your certification card is automatically processed upon your completion of training. When you initially register at MySSI you will receive an email from SSI with your Username and Password. Additionally, you will be provided a link to the SSI Privacy Policy describing how your personal data will be used. Activation of your MySSI account is mandatory to access your personal profile, training progress, certifications, education level and much more. Upon completion of all academic, pool and open water training, SSI will process your digital certification card information – Your Name, Customer Number (Master ID), SSI Training Center, Certifying Instructor, Year You Started Diving, Level of Experience, Number of Dives, and Issue Date. All this information is accessible through our MySSI account. The described processing is necessary for the performance of a contract (Article 6 (1) (b) General Data Protection Regulation). By registering in MySSI, you are consenting to share your personal data: Name (First and Last), Address (Postbox), Postcode (Zip), City, State, Country, Email Address, Telephone Numbers (optional), Date of Birth, Photo, Language, Gender, SSI Master ID, Course Type, Course Progress and Certification Information (Name, SSI Training Center, Certifying Instructor, Year You Started Diving, Level of Experience, Number of Dives and Issue Date), plus your Training Center Affiliation. Additionally, you are consenting to share all personal information voluntarily provided by you and stored in MySSI (e.g. – specific diving insurance policies (when applicable), Medical Statement for Student and Professional) for processing certification through other SSI Service Centers. You may choose to affiliate or do business with any SSI Service Center or SSI Training Center around the world. For a complete list of all Service Centers and Training Centers log on to https://my.divessi.com/ssi or https:// my.divessi.com/divecenter. By giving your consent, SSI Training Centers may subsequently access your personal data described above in order to identify you, verify or confirm the status of your training and certifications and to offer you continued training and services based on your diving experience. For more information on the relevant data processing and data sharing accessed in the MySSI system, go to MySSI Privacy Policy https:// my.divessi.com/myssi_privacy. Legal basis for the described processing is consent (Article 6 (1) (a) General Data Protection Regulation).

4. Special rules for youth under the age of 16 Youth under the age of 16 cannot participate in any SSI training without the explicit consent of their parent or legally appointed guardian. Personal data for youth under the age of 16 is only used for conducting training and issuing certifications as described above. Youth under the age of 16 who visit www.diveSSI.com cannot register or use the MySSI system without consent from their parent or legal guardian. SSI strongly recommends that the parent or legal guardian closely monitor their youth’s internet activities until they are of legal age.

5. Transferring your personal data to third parties In the event of a diving incident or a complaint against an SSI Professional, your SSI Training Center may transfer your personal data to SSI (SSI International GmbH, Johann-Hoellfritsch-Straße 6, 90530 Wendelstein, Germany) by email to info@diveSSI.com. As required by law, it may also be necessary to forward this same information to other SSI Service Centers or third parties involved in a case or in the performance of this agreement, e.g. – insurance companies, public authorities or other companies affiliated with SSI. This is only as necessary for fulfilling the training requirement, complying with legal obligations and ensuring our legitimate interests. Your SSI Training Center will also transfer your personal data to SSI while storing and processing your personal data. If necessary, this includes the Medical Statement for either the student or the SSI Instructor/Professional for the administration and processing of your training and certifications managed by SSI in the MySSI system – my.diveSSI.com. The purpose of processing and storing your personal data is necessary for the legitimate interests pursued by SSI (Article 6 (1) (f) General Data Protection Regulation). We may also transfer your personal data to the following service providers in order to complete your training: • IT service providers and/or providers of data hosting services; • Service providers of software solutions who also support SSI in providing services including marketing tools, marketing agencies, communication service providers and call centers; • Third parties that provide service to you, e.g. - parcel services for the shipment of your credentials, payment service providers and banks for processing payment; • Other necessary third parties, e.g. - auditors, insurance companies, legal representatives, etc.; • Officials and other public entities as required by law, e.g. - tax authorities, etc.; and, • Industry partners within the dive industry for the purpose of personalized advertising of diver training, products and services with the user’s consent. This includes, for example, advertising for diving insurance, membership for divers, promotion of local training programs and events conducted by Training Centers, etc. The processing is necessary for the purposes of the legitimate interests pursued by us (Article 6 (1) (f) General Data Protection Regulation). SSI will transfer your personal data to external service providers only when third parties are processing the data on our behalf. We will enter into a data processing agreement to ensure that both the security of your data and our information is only used in accordance with our Privacy Policy.

6. Transferring your personal data to third parties outside of the US/EU/EEA SSI will transfer your personal data to SSI Service Centers or other contractual partners outside the US/EU/EEA for verification of your SSI training and certifications. However, such transfers do not change anything in our obligation to protect your personal data in accordance with this Privacy Policy. We will only transfer personal data to a third party or international organization if the controller has provided the appropriate safeguards. When information is transferred outside the US/EU/EEA and whether this is to an SSI affiliate or vendor in a country that is not subject to an adequacy decision by the EU Commission, data is adequately protected by the EU Commission approved standard contractual clause; https://ec.europa.eu/info/strategy/justice-and-fundamental-rights/data-protection/data-transfers-outside-eu/model-contracts-transferpersonal-data-third-countries_en. For more information on appropriate Privacy Shield certification go to: https://www.privacyshield.gov, or for a vendor’s Processor Binding Corporate Rules, see: https://ec.europa.eu/info/strategy/justice-and-fundamental-rights/data-protection/ data-transfers-outside-eu/binding-corporate-rules_en.

7. Data Security SSI takes an appreciable amount of technical and organizational security to protect your personal data from unintentional or unauthorized modification, deletion, loss, theft, viewing, forwarding, reproduction, use, alteration or access. SSI and our staff comply with confidentiality and data privacy regulations. Likewise, all authorized agents who have access to your personal data to fulfill their professional duties are also subject to the same obligations of confidentiality and data privacy.

8. Data Retention SSI will retain your personal data to the extent permitted in the Privacy Policy. After the end of that relationship, SSI will only retain your records to perform the purposes set out in this agreement. Additionally, SSI and local law may require your SSI Training Center to retain your training records for an extended period of time. While in other cases, SSI may only need to retain your personal data for as long as it takes for administration purposes and to protect itself from any legal claims. For more information about SSI data retention policies, go to; https:// my.divessi.com/myssi_privacy. In the case of a registered user that does not activate the MySSI account and does not get certified within 12 months after registration, the user data and account will automatically be user disabled from the MySSI system. For more information about the MySSI data retention policies, go to MySSI Privacy Policy at https://my.divessi.com/myssi_privacy. 9. Your Rights Your rights regarding SSI processing and storage of your personal data: • You have the right to access and receive a copy of your personal data at SSI, Art. 15 General Data Protection Regulation (GDPR). • If your personal data is incorrect or no longer current, you have the right to modify the information, Art. 16 GDPR. • You have the right to obtain verification your personal data has been deleted from MySSI, (“right to be forgotten”), Art. 17 GDPR. • You have the right to receive a copy of your personal data in a commonly used and legible format. You also have the right to know that we may transmit your data to another controller Art. 20 GDPR. • You have the right to obtain a copy of any restriction of processing where the prerequisites have been met, Art. 18 GDPR. • You have the right to not be the subject of a decision based solely on an automated process, including profiling, which may result in legal consequences or any similar affect concerning you, Art. 22 GDPR. 10. Your right to object Where your personal data is concerned for the use of direct marketing, you have the right to object to that use. Additionally, if we process your data even for legitimate reasons, you also have the right to object at any time if grounds develop out of your specific situation. So that SSI may process your inquiry regarding the rights listed above and ensure your personal data is not given to any unauthorized third parties, please email SSI a short description and clear direction regarding your request to object and or modify your personal data stored at SSI. You also have the right to file a complaint with the data protection authority. In particular, the data protection authority in the country or state of your residence or place of work, if you believe that processing your personal data violated applicable data protection laws, Art. 77 GDPR.

 

By signing this Privacy Policy, I agree to be responsible for the content of this page.

Participants Signature

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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical Statement & Questionnaire

Diver Medical Statement & Questionnaire

Please read this Medical Statement carefully before completing the Diver Medical Questionnaire. This Medical Statement informs you of some potential risks involved in Freediving/Breath-Hold, Recreational Scuba and Extended Range ("XR") Technical Diving. You must complete and sign the Medical Questionnaire to enroll in and participate in the dive training program. If you are a minor, your parent or guardian  must sign the Medical Questionnaire.

Diving is an exciting and demanding activity. When performed cautiously, applying correct techniques, and using proper equipment, diving is relatively safe. When proper diving procedures are not followed the risk of an accident resulting in potentially serious injury, illness and even death increases. To dive comfortably and confidently you need to be reasonably fit and not extremely overweight. Diving can be strenuous even under the best conditions. Your respiratory and circulatory systems must be in good health. All your body's air spaces must be normal and healthy.  A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem should not dive.  Do NOT dive if under the influence of alcohol, marijuana (or any substance containing THC), amphetamines, cocaine, methamphetamines, opioids of any type (oxycontin, sufentanil, heroin, fentanil), hallucinogens (LSD, psilocybin mushrooms), flunitrazepam (roofies), GHB (ecstasy) or Ketamine. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your physician before participating in this program. If your future medical condition changes such that you would answer "YES" to any of the medical questions in the future, then you should consult your physician before diving. You are responsible for maintaining appropriate health and fitness to dive.

During dive training you will learn important rules and techniques regarding breathing and equalization while diving. It is essential you follow those rules and techniques for your well-being. Improper dive technique, improper use of dive equipment and improper breathing may cause serious injury or death. You must be thoroughly instructed in how to dive under the direct supervision of a qualifiled instructor before attempting to dive in the absence of an instructor.

If you have any questions regarding this Medical Statement or the Medical Questionnaire, review them with your instructor and physician before signing. If at any time during your dive training, you do not feel well or your medical condition has changed since you completed the Medical Questionnaire, then you should inform your instructor and refrain from diving.

Many divers have common conditions that benefit from specialized equipment such as masks with corrective lenses for those who wear glasses or contacts, and custom fit mouthpieces for those who have dental issues or TMJ (temporomandibular joint) issues. Ask your instructor if you think you would be more comfortable diving with these types of specialized dive equipment.

Many private and corporate personal medical policies, and even international travel insurance policies, consider diving a hazardous recreational activity, and will not provide coverage or reimburse hyperbaric chamber, outpatient expenses, or emergency transportation related to injuries while diving. These treatments can be expensive and time-consuming, and often have large out-of-pocket deductibles, co-pays, or no coverage at all. For this reason, SSI strongly recommends purchasing an additional insurance plan that specifically covers diving-related emergencies, emergency transport, and medical treatments. These policies are available through a variety of third-party providers, and should be obtained prior to any in-water training or travel related to diving.

Diver Medical Questionnaire

The purpose of this Medical Questionnaire is to determine if you should be examined by and consult with your physician before participating in Freediving/ Breath-Hold, Recreational Scuba and/or Extended Range ("XR") Technical Dive training. A positive ("YES") response to a question does not necessarily disqualify you from diving. A "YES" 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 participating in diving activities.

Please answer the questions below by writing in the word "YES" or "NO". If you are not sure, answer "YES". If any of these conditions apply to you, we request that you consult with a physician prior to participating in dive training. You must download the Guidelines for Recreational Scuba Diver's Physical Examination, the Medical Statement, this Medical Questionnaire and a Physician's Approval to Dive form to take to a physician. After you have consulted with a physician and the physician has completed and signed the Physician's Approval to Dive form, then provide the completed Dive Medical Questionnaire and Physician's Approval to Dive form to your instructor.

Medical History

Could you become pregnant, or are you attempting to become pregnant?*
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
Are you over 45 years of age and currently smoke a pipe, cigars, or cigarettes *
Yes
No
Are you over 45 years of age and have a high cholesterol level *
Yes
No
Are you over 45 years of age and have a family history of heart attacks or strokes *
Yes
No
Are you over 45 years of age and are currently receiving medical care *
Yes
No
Are you over 45 years of age and have high blood pressure *
Yes
No
Are you over 45 years of age and have diabetes mellitus, even if controlled by diet alone *
Yes
No

Have you ever had or do you currently have....

Asthma, or wheezing with breathing, or wheezing with exercise?*
Frequent or severe attacks of hayfever or allergy?*
Frequent colds, sinusitus, or bronchitus?*
Any form of lung disease?*
Pneumothorax (collapsed lung)?*
Other chest disease or chest injury?*
Behavioral health, mental or psychological problems (panic attack, fear of closed or open spaces)?*
Epilepsy, seizures, convulsions or take medications to prevent them?*
Recurring migraine headaches or take medications to prevent them?*
Blackouts or fainting (full/partial loss of consciousness)?*
Frequent or severe suffering from motion sickness (seasickness, carsick, etc.)?*
Dysentery or dehydration requiring medical intervention?*
Any dive accidents or decompression sickness?*
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
Head injury with loss of consciousness in the past five years?*
Recurrent back problems?*
Back or spinal injury?*
Diabetes?*
Back, arm or leg problems following surgery, injury or fracture?*
High blood pressure or take medication to control blood pressure?*
Heart disease?*
Heart attack?*
Angina, heart surgery or blood vessel surgery?*
Sinus surgery?*
Ear disease or surgery, hearing loss or problems with balance?*
Recurrent ear problems?*
Bleeding or other blood disorders?*
Hernia?*
A colostomy or ileostomy?*
Recreational drug use or treatment for or alcoholism in the pastfive years?*
First Participant's Signature*
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 or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
YOUTH ADDENDUM – Incorporated as an Addendum to the Assumption of Risk, Liability Release & Hold Harmless Agreement NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF THE RELEASED PARTIES USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM, YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM THE RELEASED PARTIES IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE RELEASED PARTIES HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM AND THE ASSUMPTION OF RISK, LIABILITY RELEASE AND HOLD HARMLESS AGREEMENT. THIS YOUTH ADDENDUM TO THE ASSUMPTION OF RISK, LIABILITY RELEASE AND HOLD HARMLESS AGREEMENT IS VALID FOR ONE YEAR FROM THE DATE OF SIGNATURE.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Statement & Questionnaire

Diver Medical Statement & Questionnaire

Please read this Medical Statement carefully before completing the Diver Medical Questionnaire. This Medical Statement informs you of some potential risks involved in Freediving/Breath-Hold, Recreational Scuba and Extended Range ("XR") Technical Diving. You must complete and sign the Medical Questionnaire to enroll in and participate in the dive training program. If you are a minor, your parent or guardian  must sign the Medical Questionnaire.

Diving is an exciting and demanding activity. When performed cautiously, applying correct techniques, and using proper equipment, diving is relatively safe. When proper diving procedures are not followed the risk of an accident resulting in potentially serious injury, illness and even death increases. To dive comfortably and confidently you need to be reasonably fit and not extremely overweight. Diving can be strenuous even under the best conditions. Your respiratory and circulatory systems must be in good health. All your body's air spaces must be normal and healthy.  A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem should not dive.  Do NOT dive if under the influence of alcohol, marijuana (or any substance containing THC), amphetamines, cocaine, methamphetamines, opioids of any type (oxycontin, sufentanil, heroin, fentanil), hallucinogens (LSD, psilocybin mushrooms), flunitrazepam (roofies), GHB (ecstasy) or Ketamine. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your physician before participating in this program. If your future medical condition changes such that you would answer "YES" to any of the medical questions in the future, then you should consult your physician before diving. You are responsible for maintaining appropriate health and fitness to dive.

During dive training you will learn important rules and techniques regarding breathing and equalization while diving. It is essential you follow those rules and techniques for your well-being. Improper dive technique, improper use of dive equipment and improper breathing may cause serious injury or death. You must be thoroughly instructed in how to dive under the direct supervision of a qualifiled instructor before attempting to dive in the absence of an instructor.

If you have any questions regarding this Medical Statement or the Medical Questionnaire, review them with your instructor and physician before signing. If at any time during your dive training, you do not feel well or your medical condition has changed since you completed the Medical Questionnaire, then you should inform your instructor and refrain from diving.

Many divers have common conditions that benefit from specialized equipment such as masks with corrective lenses for those who wear glasses or contacts, and custom fit mouthpieces for those who have dental issues or TMJ (temporomandibular joint) issues. Ask your instructor if you think you would be more comfortable diving with these types of specialized dive equipment.

Many private and corporate personal medical policies, and even international travel insurance policies, consider diving a hazardous recreational activity, and will not provide coverage or reimburse hyperbaric chamber, outpatient expenses, or emergency transportation related to injuries while diving. These treatments can be expensive and time-consuming, and often have large out-of-pocket deductibles, co-pays, or no coverage at all. For this reason, SSI strongly recommends purchasing an additional insurance plan that specifically covers diving-related emergencies, emergency transport, and medical treatments. These policies are available through a variety of third-party providers, and should be obtained prior to any in-water training or travel related to diving.

Diver Medical Questionnaire

The purpose of this Medical Questionnaire is to determine if you should be examined by and consult with your physician before participating in Freediving/ Breath-Hold, Recreational Scuba and/or Extended Range ("XR") Technical Dive training. A positive ("YES") response to a question does not necessarily disqualify you from diving. A "YES" 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 participating in diving activities.

Please answer the questions below by writing in the word "YES" or "NO". If you are not sure, answer "YES". If any of these conditions apply to you, we request that you consult with a physician prior to participating in dive training. You must download the Guidelines for Recreational Scuba Diver's Physical Examination, the Medical Statement, this Medical Questionnaire and a Physician's Approval to Dive form to take to a physician. After you have consulted with a physician and the physician has completed and signed the Physician's Approval to Dive form, then provide the completed Dive Medical Questionnaire and Physician's Approval to Dive form to your instructor.

Medical History

Could you become pregnant, or are you attempting to become pregnant?*
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)*
Are you over 45 years of age and currently smoke a pipe, cigars, or cigarettes *
Yes
No
Are you over 45 years of age and have a high cholesterol level *
Yes
No
Are you over 45 years of age and have a family history of heart attacks or strokes *
Yes
No
Are you over 45 years of age and are currently receiving medical care *
Yes
No
Are you over 45 years of age and have high blood pressure *
Yes
No
Are you over 45 years of age and have diabetes mellitus, even if controlled by diet alone *
Yes
No

Have you ever had or do you currently have....

Asthma, or wheezing with breathing, or wheezing with exercise?*
Frequent or severe attacks of hayfever or allergy?*
Frequent colds, sinusitus, or bronchitus?*
Any form of lung disease?*
Pneumothorax (collapsed lung)?*
Other chest disease or chest injury?*
Behavioral health, mental or psychological problems (panic attack, fear of closed or open spaces)?*
Epilepsy, seizures, convulsions or take medications to prevent them?*
Recurring migraine headaches or take medications to prevent them?*
Blackouts or fainting (full/partial loss of consciousness)?*
Frequent or severe suffering from motion sickness (seasickness, carsick, etc.)?*
Dysentery or dehydration requiring medical intervention?*
Any dive accidents or decompression sickness?*
Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?*
Head injury with loss of consciousness in the past five years?*
Recurrent back problems?*
Back or spinal injury?*
Diabetes?*
Back, arm or leg problems following surgery, injury or fracture?*
High blood pressure or take medication to control blood pressure?*
Heart disease?*
Heart attack?*
Angina, heart surgery or blood vessel surgery?*
Sinus surgery?*
Ear disease or surgery, hearing loss or problems with balance?*
Recurrent ear problems?*
Bleeding or other blood disorders?*
Hernia?*
A colostomy or ileostomy?*
Recreational drug use or treatment for or alcoholism in the pastfive years?*
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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