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Columbia Scuba's Health Screening
for Students, Divers and Staff: 


Welcome to Columbia Scuba's Health Screening for students, divers and staff. We are utilizing recommended screening questions to help ensure that we do our best to keep each other healthy and safe. We appreciate you completing this form today and inform Columbia Scuba immediately should your status change. Thank you for participating!

First Diver's Name

First Name*

Last Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email*

Confirm Email*
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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Health Screening Questions:
Diver Status:*
Student
Fun Diver
Divemaster
Instructor
Other

Date I will be diving *
Select the following:*
I am currently experiencing one or more of the following: Cough, shortness of breath, difficulty breathing, a fever, new muscle pain, a sore throat, a new loss of taste or smell, gastrointestinal symptoms like nausea, vomiting or diarrhea. (If you select this option, please contact Columbia Scuba. We will gladly reschedule your dives for a future date.)
I am healthy and am not experiencing symptoms including cough, shortness of breath, difficulty breathing, a fever, new muscle pain, a sore throat, a new loss of taste or smell, gastrointestinal symptoms like nausea, vomiting or diarrhea. I agree that for the duration of my course it is my responsibility to notify Columbia Scuba should my condition change and that I will reschedule my training at a time when I am well.
Only staff and students who are healthy should go diving and/or attend classes. This is no different from at any time in the past but is especially important now. Also, those who may have been exposed to or tested positive for COVID-19 (or other communicable disease) should avoid others until it's clear there is no transmission risk as advised by medical professionals. I agree that for the duration of my course it is my responsibility to notify Columbia Scuba should my condition change and that I will reschedule my training at a time when I am well. I accept any and all risks to me and will hold my instructor(s) and Soda City Divers LLC (Columbia Scuba) harmless. **
I agree
I do not agree
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*

Last Name*

Phone*
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 Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. 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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