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SDI Student Form

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Student Information.

Personal and Confidential
Name*
First Last
Birthdate*
DD dash MM dash YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Emergency Contact
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*

What Course Are You Registering For?*
Based on the calendar to the right. Please type in when you would like to start the classroom session of your course.
DD slash MM slash YYYY
Based on the calendar to the right. Please type in when you would like to do your pool session for your course.
DD slash MM slash YYYY
Based on the calendar to the right. Please type in when you would like to do the open water of your course.
DD slash MM slash YYYY

Help Us Have The Right Size Gear Ready For You (optional)
Height (ft/in)
Weight (lbs)
Shoe Size

Have You Ever Participated In Diving Before? Where/When?
Where?
When?
How Did You Hear About Us?
- Referred by friend
- Search Engine
- Social Media
- Yellow Pages
- Referred from other website
- Other
What Other Diving Courses Interest You?
- Advanced Open Water
- Rescue Diver
- Divemaster
- Master Scuba Diver
- Assistant Instructor
- Instructor
What Specialties Interest You?
- Advanced Adventure Diver
- Advanced Buoyancy Control
- Altitude Diver
- Boat Diver
- Computer Diver
- Computer/Nitrox
- Deep Diver
- Drift Diver
- DPV Diver
- Drysuit Diver
- Equipment Specialist
- Full Face Mask Diver
- Ice Diver
- Marine Ecosystems Awareness Diver
- Night/Limited Visibility Diver
- Research Diver
- Search and Recovery Diver
- Shore/Beach Diver
- Solo Diver
- Underwater Collector and Hunter
- Underwater Navigation
- Underwater Photography
- Underwater Videography
- VIP Diver
- Wreck Diver
Are You Interested In Scuba Travel? Which Destinations Interest You?
- Australia
- Bahamas
- Belize
- Bermuda
- Bonaire
- California
- Cayman Islands
- Costa Rica
- Cozumel
- Florida
- Hawaii
- Roatan

Medical Statement

Participant Record. Confidential Information
The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities.
Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver’s Physical Examination to take to your physician.
Yes/No*
Could you be pregnant, or are you attempting to become pregnant?
Yes/No*
Are you presently taking prescription medications? (with the exception of birth control or anti-malarial)
Yes/No*
Are you over 45 years of age and can answer YES to one or more of the following?
-currently smoke a pipe, cigar, or cigarettes? -have a high cholesterol level -have a family history of heart attack or stroke -are currently receiving medical care -have high blood pressure -diabetes mellitus. Even if controlled by diet alone.
Have you ever had or do you currently had...*
- Asthma, or wheezing with breathing, or wheezing with exercise?
- Frequent or severe attacks of hayfever or allergy?
- Frequent colds, sinusitis or bronchitis?
- Any form of lung disease?
- Pneumothorax (collapsed lung)?
- Other chest disease or chest surgery?
- Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)?
- Epilepsy, seizures, convulsions or take medications to prevent them?
- Recurring complicated migraine headaches or take medications to prevent them?
- Blackouts or fainting (full/partial loss of consciousness)?
- Frequent or severe suffering from motion sickness (seasick, carsick, etc.)?
- Dysentery or dehydration requiring medical intervention?
- Any dive accidents or decompression sickness?
- Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)?
- Head injury with loss of consciousness in the past five years?
- Recurrent back problems?
- Back or spinal surgery?
- Diabetes?
- Back, arm or leg problems following surgery, injury or fracture?
- High blood pressure or take medicine to control blood pressure?
- Heart disease?
- Heart attack?
- Angina, heart surgery or blood vessel surgery?
- Sinus surgery?
- Ear disease or surgery, hearing loss or problems with balance?
- Recurrent ear problems?
- Bleeding or other blood disorders?
- Hernia?
- Ulcers or ulcer surgery ?
- A colostomy or ileostomy?
- Recreational drug use or treatment for, or alcoholism in the past five years?
- None of the above
The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.
Signature*
Date*
MM slash DD slash YYYY
Signature of Parent or Guardian (where applicable)
Date
MM slash DD slash YYYY

SAGUARO SCUBA
908 E Impala Ave,
Mesa, AZ 85204
[email protected]
Phone: (877) 837-7637
Local: (480) 507-3988
Fax: (480) 892-7474
Hours:
Monday – Friday: 10:00 – 6:00
Saturday: 10:00 – 5:00

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