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Are you (Veteran) already a certified scuba diver?
City and State
First Name *
Last Name *
Name
First Name
Last Name
Military Service
Select all you have served in
You MUST be able to swim 200 yards without any swim or buoyancy aids without stopping
You MUST be able to float or tread in water too deep to stand for ten (10) minutes, your face must remain clear of the water for the duration of the exercise.

The purpose of this Statement of Understanding is to provide you with the important responsibilities you have with becoming a recipient of the Undersea Warriors scuba classes and conservation work. There is a lot of time, energy, and money invested by our volunteers, donors, board of directors, chapters, and instructors to make sure you have a wonderful time on your Open Water class, Nitrox class and Conservation events. It's very important that these resources are not wasted. Undersea Warriors will be working with the dive center to provide all necessary scuba equipment and training for yours and your Dive Buddy's Open Water and Nitrox Certifications.

Agreement and Next Steps - please read and check the box for each item.*
To be eligible for the program, I (Veteran) must provide legal proof of my service-related PTSD diagnosis
Once we (Veteran and Dive Buddy) have been notified of the two courses dates, we will complete and turn in all prerequisite items no later than one week prior to their start dates and notify our Chapter Team Leader of their completion.
We (Veteran and Dive Buddy) understand that we am expected to participate in Undersea Warrior class, conservation, and diving events to support fellow Veterans struggling with PTSD when possible
Media Release Statement

• As part of our program, we will be taking photos and video of events in which you may be participating. We also store your information on a secure internet cloud in order for our team to access it for training and planning needs. For these reasons, we ask that YOU read the following statements IN FULL before checking the box.

We (Veteran and Dive Buddy) have agreed to participate in the above identified Undersea Warriors Open Water Diver and Nitrox Certification Program, which we understand may be duplicated and distributed to the general public. We hereby assign and grant to Undersea Warriors and those acting under its permission, all rights, all title and interest in any intellectual property we may have in such Program and the unqualified right to use my image, name, likeness, voice and information about us for all purposes, commercial, web/social media, or otherwise as the Undersea Warriors sees fit including publicity about the Program or promotional purposes. We also understand that our voice and likeness may be recorded and /or edited, and that it may be published in any manner and for uses that the Undersea Warriors Foundation may deem appropriate. We agree that my name, likeness, voice and information about me may be used for publicity about the Program or promotional purposes. We (Veteran and Dive Buddy) hereby release Undersea Warriors, its licensees and assignees, from all claims or causes of action that may arise in whole or in part from the broadcast or any other use of a promotion for such a Program, including, but not limited to, invasion of privacy rights, defamation and violation of any intellectual property right that we have in such Program.
Privacy Statement
We (Veteran and Dive Buddy) understand and agree that for the purpose of diver training and travel planning, Undersea Warriors will retain the personal information we have provided to them during our training which includes, but is not limited to, our name, mailing address, phone number, date of birth, photography, and passport number. This personal information will be stored in Undersea Warriors’ database. Undersea Warriors will take the reasonable steps to ensure that this data is protected. This personal information will be stored in Undersea Warriors’ database. Undersea Warriors will take the reasonable steps to ensure that this data is protected. We consent to Undersea Warriors accessing this information for purposes of verifying our information and completing our training.

Statement of Understanding

We (Veteran and Dive Buddy) will provide an updated Medical Statement form with my physicians signature if we have any changes in our medical profile.
If our (Veteran and Dive Buddy) contact information changes, we will let the staff of Undersea Warriors know.
We (Veteran and Dive Buddy) notify the Undersea Warriors staff immediately of any change in our medical condition.
Communications
I will communicate as quickly as possible with my instructor, my chapter, and Undersea Warriors. The best form of communication for me is (please check all that apply):

PTS Evaluation

Level of Functioning in Relation to PTS: Individual or Family Evaluation

* Check low, moderate or high level of functioning for each area. Definitions are as follows:

Low Functioning – severe difficulty or impairment with serious and persistent signs and symptoms

Moderate Functioning – moderate difficulty or impairment with moderate to serious signs and symptoms

High Functioning – minimal difficulty or impairment with no or minimal signs and symptoms

* An answer of Low requires statement explaining difficulty
Health Status
Emotional Stability
Family Relations
Social Supports
Legal Problems
Job / Education
Housing
What do you hope to gain from the program?
Additional Notes and Comments
How did you hear about us?
Please check all that apply