Medical Statement and Photograph/Video Release & Privacy Release.

Thank you very much for your application, before we can progress with your application we require you to download, complete and return the forms attached.

If you are reading this it’s because you have started the application process to learn to scuba dive and join our adaptive diver program. If you are a veteran, we thank you for your service to our country. Scuba diving is an adventure and a joy that you can experience for the rest of your life.

In order to qualify for scuba diving, you must pass a medical qualification that all divers must pass. The medical issues we are concerned about include cardio-respiratory health and the taking of prescribed drugs.  You may still be able to dive with these medical conditions but you must have your Medical Doctor (MD) or Doctor of Osteopathy (DO) sign the form releasing you BEFORE we can begin the program.

Please download the medical statement form and instruction for your MD or DO.

Regarding the Medical Statement

  1. The portion of the medical statement regarding your instructor, their facility and the facility’s location will be completed once we have the details of your training confirmed.
  2. Any usage of subcutaneous pumps for pain management or for managing muscle spasms or implanted devices is contra-indicated because of the risk of rupture during the dive.  Ventriculoperitoneal (VP) shunts are also a risk for reverse pressure of fluid into the shunt into the cranial cavity.

Regarding the MD’s or DO’s sign-off.

  1. The purpose of the medical questionnaire is to find out your current medical condition prior to participating in an adaptive diver program.
  2. A copy of the guidelines for recreational adaptive scuba diver’s physical examination are provided so that they can be taken to your physician for clarification.
  3. This signature must be made by a MD or DO, unfortunately in this instance a Physicians Assistant (PA) or Nurse Practitioner NP) is NOT valid.

For applicants with Spinal Cord Injury (SCI), please download and complete this additional form.

  1. SCI Medical Questionnaire

Media and Privacy Release form

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 download, sign and return the Media and Privacy Release.

Please return your completed Medical Statement, Photograph/Video Release & Privacy Release and where applicable the SCI Medical Questionnaire via

email to:

mail to:       Dive Pirates Foundation

    PO Box 1564

    Wellington, CO 80549

or by fax to: 832-442-3318

If you have questions surrounding your application please call Susan DeVore, Executive Director at 877-393-3483

We all look forward to meeting you and starting you on your next adventure.