Diver Activities Consent Form
Please read and complete the following form to provide your consent for participating in diver activities.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Conditions or Allergies (if any)
Do you have any previous diving experience?
Yes
No
If yes, please provide details
Do you have a valid diving certification?
Yes
No
If yes, please provide certification details
Have you completed a medical examination within the last 12 months?
Yes
No
If yes, please provide the date of the examination
 -
Month
 -
Day
Year
Date
Have you ever had a diving-related injury or incident?
Yes
No
If yes, please provide details
Please read the following statement and check the box to indicate your consent: I understand that diving carries inherent risks and that I am responsible for my own safety while participating in diver activities. I have read and understood the rules and guidelines provided by the dive center/organization and I agree to abide by them. I release the dive center/organization from any liability for injuries or accidents that may occur during the course of diving activities.
I consent to participate in diver activities and agree to the terms and conditions stated above.
Submit
Should be Empty: