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High Plains Scuba - Customer Registration

High Plains Scuba Customer Success Agreement

Hello and welcome to High Plains Scuba and the adventures that await you.

This document assures a mutual understanding of the necessary components to provide you with a high quality of training while maintaining your safety. To ensure your success we wish to engage you in the following mutual agreement…

Class Placement

  • Placement in the requested class will only occur after the following 4 steps are fully completed and approved by the training department at least 7 days prior to class start:
  1. This document is initialed and signed.
  2. A unique SSI profile is created for yourself or represented minor(s).
  3. Full payment is received. (Fully refundable or transferable up to 7 days prior to class.)
  4. Class documents completed and approved along with any necessary medical signatures on the provided SSI forms.

I understand and agree to this class placement policy:

I Agree

Scheduling:

  • We understand that “life happens”. If you need to reschedule a class within 7 days of class start time, there is a rescheduling fee of 50% of the class cost.
  • Canceling a class within 7 days of class start time or failure to appear or complete the class in the scheduled time frame is 100% non-refundable.
  • Failure of class to fill: A minimum number of students is required per class. If we do not meet this minimum, we will offer an equivalent class at a later date for no additional charge or we can also work with you on a private upgrade.
  • Classes that must be completed within 2 weeks of payment are considered a rush and incur a $50 non-refundable charge.

I understand and agree to this scheduling policy:

I Agree

Medical

  • Safety is the highest priority. As such, all of our water-based classes require an internationally approved medical questionnaire for diving. Depending upon your honest answers, an MD or DO signature might be required on the provided SSI form. If your SSI medical form requires an approval, please understand this takes time. Thus, the SSI Medical form needs to be returned to the training department at least 7 days prior to class start time or we will work with you to reschedule you in another class for a $30 rescheduling fee.

I understand and agree to this medical policy:

I Agree

Coursework

  • Part of your adventure is the digital material. This material is what will set you on a safe and fun adventure. After steps 1-3 are done, coursework and associated paperwork to complete will be assigned. We suggest you leave the coursework unopened until you have been confirmed into your class by the training department as opened coursework or sold as a bundle cannot be refunded. Coursework including any online finals must be completed prior to class start.

I understand and agree to this coursework policy:

I Agree

Open Water Certification Class and Open Water Certification Trips:

  • Students are responsible for having their own mask, snorkel, fins/booties.
  • Rooms are based on double-occupancy. If a suitable roommate is not available or if you choose to have a private room, you will be charged the full room rate.
  • Rooms are non-smoking. Violations will incur a special cleaning fee (minimum $160).
  • Weather cancellation and rescheduling:
  • No charge to reschedule if HPS cancels for safety reasons due to road or weather conditions.
  • $50 pp rescheduling fee if customer chooses to reschedule for safety reasons due to road or weather conditions, but HPS is still going.
  • No refunds will be offered. Referral or reschedule options will be made available.
  • You will be responsible for transporting tanks, weights, BCDs and regulators to/from the Open Water Location in the prescribed time. Inability to do so will result in an additional fee and might not be possible based on a variety of factors.
  • While we certainly would like to have you on our certification trips, we understand that you might wish to finish your certification elsewhere. Please understand that due to the competitive nature of the certification agencies around the world, your Open Water Certification must be completed at a SSI Training Center. We cannot offer referrals to non SSI facilities (PADI, NAUI, SDI, etc.).

I understand and agree to this Open Water Certification policy:

I Agree

Image release

  • High Plains Scuba has my permission to use my image/likeness publicly to promote the business. I understand the images may be used in print material, website and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I understand and agree to this image release policy:

I Agree

Date: May 1, 2026

First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Second Participant's Signature*
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Third Participant's Signature*
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Fourth Participant's Signature*
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Fifth Participant's Signature*
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Sixth Participant's Signature*
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Seventh Participant's Signature*
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Eighth Participant's Signature*
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Ninth Participant's Signature*
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
Tenth Participant's Signature*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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:*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Age:

Diver Information

Certified Open Water Diver: *
No
Yes
Date of Last Dive:
Certification agency (SSI, PADI, NAUI)
Certification#:
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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