Coaching Client Registration, Medical History, and Waiver

Congratulations on beginning your journey in the UTD Scuba Coaching program. We have just one more bit of paperwork for you, the waiver/medical history form:

UTD Registration, Medical History Form, and Waiver

Student Name*
First Last
Student Email*
Enter Email Confirm Email
Student Gender*
- Male
- Female
Student Phone*
Student Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Student's UTD Number (if known)
Choose Class – If taking multiple class, ctl-click (or cmd-click on Mac) to select more than one.*
If other class, please note here.
UTD Instructor*
UTD Instructor Email
UTD Dive Center
UTD DIve Center Email
If other dive center, please note
Are you a certified diver?*
- Yes
- No
- Yes, but inactive
If yes, what agency?
If yes, what level?
If yes, approximately how many dives?
Please tell us a little about your diving background and why you are taking this course.
How did you learn about UTD?
MEDICAL HISTORY SECTION. I understand that if I answer "yes" to any of the following questions I will need a physician's release to dive. This includes your pool, or confined water sessions.*
- I understand
Date of Birth*
DD dash MM dash YYYY
Behavior Health Problems*
- Yes
- No
Claustrophobia*
- Yes
- No
Diabetes*
- Yes
- No
Epilepsy*
- Yes
- No
Agoraphobia*
- Yes
- No
Migraine Headaches*
- Yes
- No
Ear and Hearing Problems*
- Yes
- No
Trouble Equalizing Ear Pressure*
- Yes
- No
Sinus Problems*
- Yes
- No
Severe Hay Fever*
- Yes
- No
Heart Trouble*
- Yes
- No
High Blood Pressure*
- Yes
- No
Heart Surgery*
- Yes
- No
Asthma*
- Yes
- No
Bronchitis*
- Yes
- No
Tuberculosis*
- Yes
- No
Respiratory Problems*
- Yes
- No
Back Problems*
- Yes
- No
Back or Spinal Surgery*
- Yes
- No
Hernia*
- Yes
- No
Recent Surgery*
- Yes
- No
Pregnancy or Suspect Pregnancy*
- Yes
- No
Severe Motion Sickness*
- Yes
- No
Serious Injury*
- Yes
- No
Hepatitis*
- Yes
- No
HIV Positive*
- Yes
- No
Drug Allergies*
- Yes
- No
Ulcers*
- Yes
- No
Taking Prescription Medication other than Birth Control*
- Yes
- No
If yes to medication, please list:
Over 45 and Family History of Heart Disease*
- Yes
- No
Over 45 and smoke tobacco*
- Yes
- No
Notes or Comments
UTD General Release of Liability and Covenant Not to Sue for Recreational, Technical and Overhead Environment SCUBA Diving, Zuba Diving, and Snorkeling.
In consideration of permitting me to participate in SCUBA diving or any other in-water activities, including preparation to enter the water, in-water, and post water activities:
1. I HEREBY acknowledge that SCUBA DIVING IS A POTENTIALLY DANGEROUS ACTIVITY and involves the risk of serious injury and/or death and/or property damage. I further acknowledge that diving with compressed air involves certain risks and injuries that can occur which require treatment in a recompression chamber or other facility which may require a great distance of travel. I understand that the activities in which I am participating may be conducted at a site that is remote, either by time or distance or both, from a recompression chamber or medical facilities.  I agree to the above paragraph.*
2. I HEREBY RELEASE, WAIVE, AND DISCHARGE the dive leader named above, UTD Scuba Diving, LLC (aka Unified Team Diving, aka Public Safety Team Diving), and any of its owners, officers, instructors, agents or employees (the Releasees) FROM ALL LIABILITY TO MYSELF, my personal representatives, assigns, heirs, and next of kin FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFOR ON ACCOUNT OF INJURY TO MY PERSON OR PROPERTY OR RESULTING IN MY DEATH, NOW AND FOREVER, ARISING OUT OF OR RELATED TO MY PARTICIPATION IN SCUBA DIVING OR ANY RELATED ACTIVITIES, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.  I agree to the above paragraph.*
3. I HEREBY ASSUME FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE, now and forever, arising out of OR RELATED TO MY PARTICIPATION IN SCUBA DIVING OR ANY RELATED ACTIVITIES, whether foreseen or unforeseen and whether caused by the negligence of the Releasees or otherwise.  I agree to the above paragraph.*
4. I HEREBY agree to INDEMNIFY and SAVE and HOLD HARMLESS the Releasees from any loss, liability, damage or cost any of them may incur, now and forever, arising out of OR RELATED TO MY PARTICIPATION IN SCUBA DIVING OR ANY RELATED ACTIVITIES, whether caused by the negligence of the Releasees or otherwise.  I agree to the above paragraph.*
5. I HEREBY acknowledge that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES and agree that this agreement and release extends to all acts of negligence by Releasees, INCLUDING NEGLIGENT RESCUE OPERATIONS. I agree to the above paragraph.*
6. I HEREBY agree NOT to SUE or otherwise assert any claim against any of the Releasees for any injury or damage I may incur as a result of my participation in SCUBA diving or any related activities. I understand that if, notwithstanding my agreement not to sue, I bring any action against Releasees for any claim released pursuant to this agreement, the prevailing party in any such action shall be entitled to recover reasonable attorneys’ fees and costs. I agree to the above paragraph.*
7. I HEREBY ACKNOWLEDGE that the Release included in this agreement is intended to be as broad and inclusive as permitted by the laws of the Province or State in which the activities are conducted and that if any portion of this agreement and release is held invalid, the balance shall continue in full legal force and effect. I agree to the above paragraph.*
8. I HEREBY ACKNOWLEDGE I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it, am aware of its legal consequences, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. I understand that this agreement represents the entire agreement between the parties regarding the subject matter hereof and supersedes any prior or contemporaneous agreements. I understand that this agreement may not be orally modified and I am not relying on representations made by anyone other than those set forth in this agreement. I agree to the above paragraph.*
I understand that this agreement represents the entire agreement between the parties regarding the subject matter hereof and supersedes any prior or contemporaneous agreements. I understand that this agreement may not be orally modified and I am not relying on representations made by anyone other than those set forth in this agreement. I agree to the above paragraph.*
BY WAY OF MY VOLUNTARY DIGITAL SUBMISSION, I AGREE THAT I HAVE FULLY READ AND UNDERSTAND THIS DOCUMENT IN ITS ENTIRETY. I UNDERSTAND THAT THIS IS A LEGALLY BINDING CONTRACT NOT TO SUE AND AGREE TO BE BOUND BY IT.
Consent*
I have read and I agree to the UTD Privacy Policy as linked from the UTD Scuba Diving website.
Digitally sign and agree by printing name below.*
After printing, sign and date the printed form below.
Consent*
By digitally submitting this document I accept its terms and conditions and I state that I am over 18 years of age.
IF PARTICIPANT IS UNDER THE AGE OF 18:
If the participant is under the age of 18, then the parent or guardian must PRINT AND SIGN this agreement and agree to be legally bound by it and furthermore be legally responsible for the minor participant, including being responsible for all damages, injury or death which may occur as a result of the minor’s participation in diving activities. The parent or guardian hereby agrees to be fully responsible to the “Released Parties” for any damage, injury or death caused by the minor, including actions brought by the minor, for any damages whatsoever.
Signature of Parent or Guardian
___________________________________________________________ Signature of Parent or Guardian ___________________________________________________________ Date

Extreme Scuba Makeover
Open Water
Advanced Open Water
Recreational 1
Recreational 2
Recreational 3
Oxygen Clean Up for Rec Divers
Essentials of Rec
Essentials of Scientific Diving
Nitrox Diver
Rescue Diver
First Aid/CPR/AED/O2 Provider
Drysuit Diver
SMB MINI
Propulsion MINI
Side Mount MINI
Back Mount MINI
Navigation MINI
Night MINI
Scooter/DPV
Underwater Video and Photo Storytelling
Essentials of Tech
Doubles MINI – Back Mount
Doubles MINI – Side Mount
Stage MINI
Techreational Diver
Tech 1
Tech 2
Tech 3
Tech Gold
Techreational CCR
Tech 1 CCR
Tech 2 CCR
Tech 3 CCR
Tech Gold CCR
Ratio Deco 3.0
Technical Gas Blender
Cylinder and Valve Technician
Dry Suit Repair Technician
Regulator Repair Technician
Essentials of Rebreather Diving
mCCR 1
mCCR 2
mCCR 3
pSCR 1
pSCR 2
pSCR 3
Overhead Protocols
Guide Line MINI
Cave 1
Cave 2 – Full Cave
Cave 3 – Full Cave
Cave Gold
Wreck 1
Wreck 2
Wreck 3
Wreck Gold
Overhead Scooter
mCCR Overhead
pSCR Overhead
Divemaster / Coach
IDC Prep
Foundational Instructor
Technical Instructor
Cave Instructor
Wreck Instructor
Side Mount Instructor
Rebreather Instructor
IT Prep
Instructor Gold
Internship-Qualified Instructor
Instructor Requalification/Upgrade
Instructor Trainer
Other

UTD Registration, Medical History Form, and Waiver

UTD General Release of Liability and Covenant Not to Sue for Recreational, Technical and Overhead Environment SCUBA Diving, Zuba Diving, and Snorkeling.

BY WAY OF MY VOLUNTARY DIGITAL SUBMISSION, I AGREE THAT I HAVE FULLY READ AND UNDERSTAND THIS DOCUMENT IN ITS ENTIRETY. I UNDERSTAND THAT THIS IS A LEGALLY BINDING CONTRACT NOT TO SUE AND AGREE TO BE BOUND BY IT.

IF PARTICIPANT IS UNDER THE AGE OF 18:

Signature of Parent or Guardian