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I affirm I am the parent and/or legal guardian of (minor). As the parent/guardian, I hereby authorize, Soda City Divers LLC dba Columbia Scuba, and/or its agents, employees or assigns, to seek medical treatment for (minor), as a result of an accident or illness while under the supervision of Columbia Scuba.

I affirm I have read the Certificate of Understanding and Express Assumption of Risk form, signed it of my own free will, and understand the legal consequences of signing the document.

I authorize the treatment of (minor), by a qualified and licensed physician in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed.

I have fully informed myself of the contents of this Emergency Treatment Consent Form by reading it before I signed it.


Today's Date: May 9, 2025

First Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
First Participant's Signature*
Second Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Third Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Fourth Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Fifth Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Sixth Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Seventh Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Eighth Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Ninth Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Tenth Participant's Name

First Name*

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

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent or Guardian's Email Address

Email*

Confirm Email*
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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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE): *
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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