UTD Waiver and Medical History Form

First Name *

Last Name *

Email Address *

Confirm Email *

Student Gender *

Male

Female

Other

Phone Number *

UTD Number (if known)

Choose Class *

If other class, please note here.

Choose Instructor

Instructor Email (if unknown, enter info@utdscubadiving.com) *

Confirm Email *

Are you a certified diver? *

Yes

No

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 *

Behavior Health Problems *

Yes

No

Claustrophobia *

Yes

No

Diabetes *

Yes

No

Epilepsy *

Yes

No

Agoraphobia *

Yes

No

Migraine Headaches (Diagnosed) *

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

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 Comments

1. 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, 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 *

By digitally submitting this document I accept its terms and conditions and I state that I am over 18 years of age.

I am under the age of 18 and my parent or guardian will sign below.

Submission Date *

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.