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SSI Introductory Scuba Experience - Fit To Dive Screening

Scuba diving is an adventurous and exciting activity, but it can also be strenuous and potentially dangerous. As with any aquatic adventure, especially those relying on underwater breathing equipment, there are inherent dangers which cannot be eliminated that may cause serious illness, injury or death. You must be in good health to dive. If you have any questions about your medical, mental or physical fitness to dive, you should consult a physician to assess your individual risk factors

This form is to help you determine if you should be examined by a physician. If you have any doubt about your fitness to dive, then you must obtain approval from a physician prior to diving. Failure to obtain a physician’s approval to dive may significantly increase your risk of illness, injury or death. You are solely responsible for honestly evaluating your fitness to dive and you are ultimately responsible for your safety and wellbeing when engaged in dive activities (including boat travel, putting on/taking off dive equipment, getting in and out of the water, etcetera).

 

Date: May 28, 2022

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

First Participant's Signature*
Second Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Second Participant's Signature*
Third Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Third Participant's Signature*
Fourth Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Fourth Participant's Signature*
Fifth Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Fifth Participant's Signature*
Sixth Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Sixth Participant's Signature*
Seventh Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Seventh Participant's Signature*
Eighth Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Eighth Participant's Signature*
Ninth Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Ninth Participant's Signature*
Tenth Participant's Name

First Name*

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

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

Tenth Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

By placing my name here, I agree to be responsible for the content of this page.

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI Dive Programs.

1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical condition?*
No
Yes
2. Do you take prescription medication(s) (not including birth control)?*
No
Yes

Do you currently have or have you been treated within the last two years for any of the following:

3. A heart, circulatory, blood, blood pressure, or bleeding abnormality?*
No
Yes
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition?*
No
Yes
5. An ear, sinus, mouth, throat, or lung disorder - including asthma?*
No
Yes
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders?*
No
Yes
7. Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?*
No
Yes

If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water diving activities. You are responsible for obtaining a completed Physician's Approval to Dive form and provide that completed form to your instructor before any in-water dive training. 

Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death. 

I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

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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