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First Name:*

Surname:*

Date of Birth:*

Date of Birth:

Home Address:*

E-mail:*

Emergency Contact: (Name and Phone and Relationship)*

Contact Phone Number:*

Privacy Policy This Privacy Policy explains why SSI Training Centers obtain your personal data for the purposes of conducting your training, issuing certifications, administration of your private information and any other necessary specifics regarding the performance of this agreement. By registering in MySSI, you are consenting to share your personal data: Name (First and Last), Address (Postbox), Postcode (Zip), City, State, Country, Email Address, Telephone Numbers (optional), Date of Birth, Photo, Language, Gender, SSI Master ID, Course Type, Course Progress and Certification Information (Name, SSI Training Center, Certifying Instructor, Year You Started Diving, Level of Experience, Number of Dives and Issue Date), plus your training center Affiliation. By giving your consent, SSI Training Centers may subsequently access your personal data described above in order to identify you, verify or confirm the status of your training and certifications and to offer you continued training and services based on your diving experience. For more information you may go to the SSI Privacy Policy at https://my.divessi.com/myssi_privacy.

I FULLY UNDERSTAND AND AGREE

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SSI Introductory Fit To Dive Screening and Responsible Diver Code

Scuba Diving is adventurous and exciting activity, but can also be strenuous and potentially dangerous. As with any aquatic adventure, especially those relying on specialized equipment, there are inherent dangers which cannot be eliminated that may cause serious illness, injury or death. You must be in good health to breath-hold dive. If you have any questions about your medical, mental or physical fitness to dive, you should consult a physician to assess your individual risk factors. This form is to help you determine if you should be evaluated by a physician. If you have any doubt about your fitness to dive, then you must obtain approval from a physician prior to diving. Failure to obtain a physician's approval to dive may significantly increase your risk of illness, injury or death. You are solely responsible for honestly evaluating your fitness to dive and you are ultimately responsible for your safety and wellbeing when engaged in dive activities (including boat travel, putting on/taking off dive equipment, getting in and out of the water, etcetera). Additionally, if you are under the influence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good judgment or you are unable to be responsible for you own wellbeing, then you have a significant increase to risks of illness, injury and death while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in serious illness, injury or death.

I FULLY UNDERSTAND AND AGREE

Answer each of the following questions about your past and present medical conditions by filling in the corresponding [NO] or [YES] box. If you are not sure, then answer [YES]. Do you currently have or have you been treated within the last 12 months for any of the following:

I UNDERSTAND

1 | A heart, circulatory, blood, blood pressure, or bleeding abnormality that affects your ability to swim?

YES
NO

2 | A breathing or lung disorder (such as asthma or shortness of breath)?

YES
NO

3 | Musculoskeletal, stamina, strength, or mobility disorders that affects your ability to swim?

YES
NO

If you answered [YES] to any of these questions, then you must additionally complete the Diver Medical Participation Questionnaire. The Diver Medical Participation Questionnaire is a more thorough medical screening form used to determine if you need to be evaluated by a physician prior to any in-water diving activities.

SSI Introductory Scuba Code I agree to be responsible to comply with the following SSI Introductory Scuba Code during all diving activities: 1 | I am responsible for my own safety and well-being during all scuba dives, including but not limited to; equalizing my air spaces, breathing normally, maintaining proper buoyancy, and remaining with my dive leader throughout the dive. 2 | I am responsible for being physically, medically, and mentally fit to participate in scuba diving; and I affirm all the personal information I have provided on the Fit to Dive questionnaire is truthful and accurate to the best of my knowledge; and I will not hold others responsible or liable for any injury, illness, or death caused by my failure to disclose a known medical condition. 3 | I am responsible for monitoring my air supply and ending my dive with at least 500 psi/35 bar. 4 | I am responsible for immediately notifying my dive leader if I am not comfortable or I have a problem. 5 | I will remain with my dive leader throughout my dive; however, if I become separated and cannot locate my dive leader, I will ascend to the surface (making sure to exhale during ascent) and establish positive buoyancy by inflating my buoyancy compensator or releasing my weights. 6 | I understand dive training does not guarantee my safety and that accidents happen even when proper procedures are followed. 7 | In the event that I do not feel comfortable, capable, or willing to fulfill these Responsibilities then I will not dive. I understand the importance of being a responsible diver and I pledge to abide by the SSI Introductory Scuba Code. I understand failure to abide by the Responsible Diver Code will jeopardize my safety and well-being. I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that affects my safety while diving.

I FULLY HAVE READ THIS STATEMENT AND UNDERSTAND IT FULLY AND REALISE THAT THIS IS A LEGALLY BINDING DOCUMENT AND CONSENT FOR THIS TO BE USED AS SUCH:

Participant's Signature and Agreement (By checking this box is agreed as a digital Signature and is usable in a court of law)

Date Field

TRY DIVE ONLINE FORMS

SSI Introductory Fit To Dive Screening and Responsible Diver Code