Student Name *
Student Email * Student Gender * Student Phone * Student Mailing Address
* Student's UTD Number (if known) Choose Class – If taking multiple class, ctl-click (or cmd-click on Mac) to select more than one. * 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 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 If other class, please note here. UTD Instructor * Choose Instructor Adrian Sapota Alan Weinberg Alan Williams Alessandro Verginella Andrea Cappa Andrea Savelli Andrej Gaspar Antonio Jiménez Rodríguez Antonio Sarnataro Ben Bos Bill Johnson Brian Wiederspan Brian Younghoon Kim Carlos Torres Casper Dreiøe Cat Harris Chew Poh Chang Christian Holzmaier Chulhyun Baek Claudio Valtz Dae Wui Jung Daniel Schelvis Darryl Owen Deb Foley Ela Bertoni Erol Ericksson EVAN KO Fabrizio Catalano Flavio Turchet Fran Kucker Giulia Garavelli Greg Wolff HAK JOON Jung Han Chongmin HOONHEE LEE INAKI DE SANTOS Iñaki Galilea Inma Marin Jackie Yu JAKE TAESU KANG James Mott Jason Park Javi Mozos Jay Gardner Jay Schier Jeanna Edgerton Jeff Christiansen Jeff Seckendorf Jens Dalsgaard Topholm Joe Rendzio Joel Hollander John Goh Jon Edwardsen JUN JOONYOUNG Kace Wong Kelvin Yu Kevin Wood Kim Cardenas Kiung Baek Kiven Zhang Kyoungsoo Han KYUNGHO KIM Letizia Mitri Lorenzo Bonemei Luca Pallaver Lukáš Ježek Marco Alberti Marco Ciani Marco De Martino Marine Canac Owen Martin Denison Martina Carelli Matt Skogebo Mauritius Bell Max Wang Michael Deckert Mike Brennan Min Dai Mirko Apostolo Mo Hammoud Namkyu Kim Namkyun Kim Neil Egerton Nico Gioffrè Nicolaj Lindegren Pete Vanags Peter Kubicka Rafael Cabello Portela Randy Tay Saad Rizk Samer Laward SangJoon Ahn Sasha Karnilovich Saufan Chkaf Seill Jang Sergi Perez Garcia Sergio Criado Shannon Buhl Sik Kim Simone Nägele Simone Nicolini Tanya Kuck Tom Carr Tony Tso Troy Droegemeyer Tyler Giblin Vicente Tasso Bermell Wu Yutong Xavi Escriva Yang Li Youngkyou Kyoung Zach Kennedy UTD Instructor Email
UTD Dive Center Choose Dive Center Abyss Tech Acuanova Aquanautics LLC Buceo Aqualia Diver Gente Freestyle Divers NOW Dive OTHER DIVE CENTER Rivemar Dive Center Style Diving Submerged UTD HQ UTD DIve Center Email
If other dive center, please note Are you a certified diver? * 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. * Date of Birth *
DD dash MM dash YYYY
Behavior Health Problems * Claustrophobia * Diabetes * Epilepsy * Agoraphobia * Migraine Headaches * Ear and Hearing Problems * Trouble Equalizing Ear Pressure * Sinus Problems * Severe Hay Fever * Heart Trouble * High Blood Pressure * Heart Surgery * Asthma * Bronchitis * Tuberculosis * Respiratory Problems * Back Problems * Back or Spinal Surgery * Hernia * Recent Surgery * Pregnancy or Suspect Pregnancy * Severe Motion Sickness * Serious Injury * Hepatitis * HIV Positive * Drug Allergies * Ulcers * Taking Prescription Medication other than Birth Control * If yes to medication, please list: Over 45 and Family History of Heart Disease * Over 45 and smoke tobacco * 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 * Digitally sign and agree by printing name below. * After printing, sign and date the printed form below. Consent * 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