UTD Waiver and 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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.*Extreme Scuba MakeoverOpen WaterAdvanced Open WaterRecreational 1Recreational 2Recreational 3Essentials of RecEssentials of Scientific DivingNitrox DiverRescue DiverFirst Aid/CPR/AED/O2 ProviderDrysuit DiverSMB MINIPropulsion MINISide Mount MINIBack Mount MININavigation MININight MINIScooter/DPVUnderwater Video and Photo StorytellingEssentials of TechDoubles MINI – Back MountDoubles MINI – Side MountStage MINITechreational DiverTech 1Tech 2Tech 3Tech GoldRatio Deco 2.0Technical Gas BlenderCylinder and Valve TechnicianDry Suit Repair TechnicianRegulator Repair TechnicianEssentials of Rebreather DivingmCCR 1mCCR 2mCCR 3pSCR 1pSCR 2pSCR 3Overhead ProtocolsGuide Line MINICave 1Cave 2 – Full CaveCave 3 – Full CaveCave GoldWreck 1Wreck 2Wreck 3Wreck GoldOverhead ScootermCCR OverheadpSCR OverheadDivemaster / CoachIDC PrepFoundational InstructorTechnical InstructorCave InstructorWreck InstructorSide Mount InstructorRebreather InstructorIT PrepInstructor GoldInternship-Qualified InstructorInstructor Requalification/UpgradeInstructor TrainerOtherIf other class, please note here. UTD Instructor*Choose InstructorAdrian SapotaAlan WeinbergAlan WilliamsAlessandro VerginellaAndrea CappaAndrea SavelliAndrej GasparAntonio SarnataroBen BosBill JohnsonBrian WiederspanBrian Younghoon KimCarlos TorresCasper DreiøeChew Poh ChangChristian HolzmaierClaudio ValtzcodyyeiserDae Wui JungDaniel SchelvisDarryl OwenDeb FoleyEla BertoniEVAN KOFabrizio CatalanoFlavio TurchetFran KuckerHAK JOON JungHan ChongminHOONHEE LEEINAKI DE SANTOSInma MarinJackie YuJAKE TAESU KANGJames MottJason ParkJavi MozosJay SchierJeanna EdgertonJeff ChristiansenJeff SeckendorfJoe RendzioJoel HollanderJohn GohJon EdwardsenJUN JOONYOUNGKace WongKelvin YuKim CardenasLetizia MitriLuca PallaverMarco AlbertiMarco Ciani Coralsub Palmanova UD ItaliaMarco De MartinoMarine Canac OwenMartina CarelliMatt SkogeboMattia PopessoMauritius BellMax WangMichael DeckertMike BrennanMin DaiMirko ApostoloMo HammoudNico GioffrèPete VanagsPeter KubickaRandy TaySaad RizkSamer LawardSangJoon AhnSasha KarnilovichSaufan ChkafSergi Perez GarciaSergio CriadoShannon BuhlSimone NägeleSimone NicoliniTanya KuckTony TsoTroy DroegemeyerTyler GiblinWu YutongXavi EscrivaYang LiZach Kennedyzuoming zhangUTD Instructor Email UTD Dive CenterChoose Dive CenterAbyss TechAcuanovaAquanautics LLCNOW DiveOTHER DIVE CENTERRivemar Dive CenterSubmergedUTD 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.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 Trouble Equalizing Ear 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 Tuberculosis* 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 Severe Motion Sickness* 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 CommentsUTD 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.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
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