Adaptive Diver Application

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Adaptive Diver Application

Adaptive Diver Application

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- All fields denoted with an * are mandatory.
- You are able to save, and then return to this form to continue with the application process. If you select this option, you will receive the link in an email.
- Please note do not upload your photo until you are ready to submit your application as it will not be saved.
Personal
Name*
Prefix First Middle Last Suffix
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Please provide the best form of communication for you (email, phone, text, facebook). Our volunteers will be organizing your training and travel and will need to be able to contact you regularly. Please respect their time and return calls or emails promptly.
Phone, best number is*
Email, best address is*
Text, best number is
Facebook Messenger, my contact details are:
With you embarking on this scuba diving adventure, it’s important we be able to stay in touch with you.
- I agree to keep Dive Pirates updated with my current contact details.
Passport details
Do you have a valid passport?*
- No
- Applying for one
- Yes
Since our program includes an international dive trip, see video below, in order for us to continue processing your application or arrange any scuba training for you, you will need to obtain a valid passport. This will be your responsibility to complete. Once you have your passport we would love to hear back from you. Please select save and continue, and follow the link provided to continue applying once you have your passport in place.
- Passport Application Process
Expiration date*
Confirmation*
Please scan or take a photo of your passport application confirmation and upload it here for our records.
Drop files here or

Max. file size: 50 MB, Max. files: 1.

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Emergency Contact Details
Emergency Contact Details*
First Last
Relationship To Me*
- Child
- Friend
- Parent
- Sibling
- Spouse/Significant Other
Emergency Phone*
Emergency Email

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Background
Have you scuba dived before?*
- Yes
- No
Tell Us More About It
When? Where? Certification? In what capacity? e.g. Combat diver
Are you currently or were you in the?*
Please check all that apply.
- Armed Forces
- First Responder Unit
- Law Enforcement Agency
- None of the above
Which branch of the military?*
- United States Air Force
- United States Army
- United States Coast Guard
- United States Marine Corps
- United States Navy
What was or is your date of discharge?
Highest rank held?*
Date joined Law Enforcement:*
Leaving date:
Please leave blank if still employed.
Date joined First Responder Unit*
Leaving date:
Please leave blank if still employed.
What inspired you to serve in the military?*
What inspired you to join Law Enforcement?*
What inspired you to become a First Responder?*
What sports, if any do you play?
Please tell us the reason you would like to learn to scuba dive?*

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Fundraising
Our foundation is donation based, are you opposed to fundraising?*
- No
- Willing to try
- Yes
There is a lot of time, energy, and money invested by our volunteers, donors, and board of directors to make sure you have every opportunity to safely learn to be an adaptive diver and have a wonderful first experience in the open ocean. We need your commitment to attend all fundraising functions held by your chapter and share your fundraising page via your social networks at a minimum. Please check out some of our diver's stories!
- INSPIRING STORIES
Would you like to reconsider fundraising?
- No
- Yes
Please share with us any ideas you have for fundraising?*
That's great, we are here to work with you and your buddy to make this happen. Help us help you make this a reality.
I'm sorry you feel that way. Maybe Dive Pirates isn't for you. We work together as a crew to support each other. If you don't want to reconsider then we wish you well on your journey.
- HOME PAGE

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Medical
What is your medical condition? Please choose the one closest to describing your medical condition.*
- Amputee
- Blind
- Cerebral Palsy
- Congenital Amputee
- Deaf
- Fused Ankles
- Hemiplegia
- Limb Salvage
- Multiple Sclerosis
- Paralysis to a limb
- Parkinson's Disease
- Rheumatoid Arthritis
- Spinal Cord Disease
- Spinal Cord Injury
Spinal Cord Injury or Disease*
- Paraplegia
- Quadraplegia
Type of Amputation*
- Elbow disarticulation
- Forequarter amputation
- Shoulder disarticulation
- Transhumoral amputation
- Transradial amputation
- Wrist disarticulation
- Partial Hand
- Transpelvic
- Hip disarticulation
- Transfemoral amputation
- Knee disarticulation
- Transtibial amputation
- Ankle disarticulation
- Syme's amputation
- Transmetatarsal amputation
Tell us about yourself, what is your story? How has your changing situation effected your day to day life*
Have you been diagnosed with PTSD?*
- No
- Yes
Please let us know what triggers your PTSD and what your reactions are to these triggers.
This information is very beneficial to your dive instructors.
Do you have Traumatic Brain Injury (TBI) or cognitive impairment?*
- No
- Yes
Please explain how this has impacted your day to day living.
Do you need mechanical assistance to breathe?*
- No
- Yes
Are you using a medicated patch or internal pump for pain management?*
- No
- Yes
Are you using an internal pump for control of muscle spasms?*
- No
- Yes
Do you have a VP Shunt for drainage of fluids from the cranial cavity?*
- No
- Yes
For your safety, we do not accept applications from candidates who have a subcutaneous pump for pain management or for managing muscle spasms, or implanted devices due to the risk of rupture during the dive. If you have a question about your situation and would like to discuss in further detail we would welcome your call. Please call us on 1-877-393-3483.
- HOME PAGE
Do you use mobility aids?*
- No
- Motorized Scooter
- Walking aids: canes, crutches, walkers
- Wheelchair
Do you use your wheelchair?*
- All the time
- Sometimes
Is your wheelchair?*
- Electric
- Manual
Please provide more information on how and when you use your mobility aids*
Please include any information on your medical condition that you feel may be appropriate to your application.

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Sizing for equipment
To enable us to provide the appropriate equipment please provide the following information.
Height*

ft/ in
Weight*

lbs
Shoe Size*
Please select your T-shirt size*
- Small
- Medium
- Large
- X Large
- XX Large
- XXX Large

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Media and Privacy Release
Media Release*
- 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.
- I have agreed to participate in the above identified Dive Pirates Foundation Program, which I understand may be duplicated and distributed to the general public. I hereby assign and grant to Dive Pirates Foundation and those acting under its permission, all rights, all title and interest in any intellectual property I may have in such Program and the unqualified right to use my image, name, likeness, voice and information about me for all purposes, commercial, web/social media, or otherwise as the Dive Pirates Foundation sees fit including publicity about the Program or promotional purposes.
  
  I also understand that my voice and likeness may be recorded and /or edited, and that it may be published in any manner and for uses that the Dive Pirates Foundation may deem appropriate. I agree that my name, likeness, voice and information about me may be used for publicity about the Program or promotional purposes. I hereby release The Dive Pirates Foundation, 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 I have in such Program.
Privacy Statement*
- I understand and agree that for the purpose of diver training and travel planning, Dive Pirates Foundation will retain the personal information I have provided to them during my training which includes, but is not limited to, my name, mailing address, phone number, date of birth, photography, and passport number.This personal information will be stored in Dive Pirates’ database. Dive Pirates will take the reasonable steps to ensure that this data is protected.
  
  This personal information will be stored in Dive Pirates’ database. Dive Pirates will take the reasonable steps to ensure that this data is protected.
  
  I consent to Dive Pirates Foundation accessing this information for purposes of verifying my information and completing my training.
  
  I further certify that I am over eighteen (18) years of age, and competent to contract in my own name in so far as the above is concerned.

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Statement of Understanding
Recipient Responsibilities: — As a recipient, I am aware and agree to:*
- The purpose of this Statement of Understanding is to provide you with the important responsibilities you have with becoming a recipient of the Dive Pirates Foundation. 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 Dive Pirates Adventure. It's very important that these resources are not wasted. Dive Pirates will be providing any necessary scuba equipment and training for you and your dive buddy.
- Please read and check the box for each item.
- Provide Dive Pirates my bio for them to build my personal diver-in-training page that I will then share with my family, friends, local community and social media networks. I’ll also actively participate in any fundraising event held by my chapter on my behalf.
- Once I have been notified of the instructor and chapter I am to work with for my training, I need to have my online academic work as well as all my pool training completed at least 90 days prior to the scheduled departure date of my trip.
- Work with my instructor and chapter to raise the funds necessary for me and my buddy’s travel and I understand if there is not enough funding I will have to wait to go on my trip.
- I will have an updated doctor’s release form completed if the one I have on file becomes out of date.
- Provide the Dive Pirate staff with details of any scheduled surgeries I have in the upcoming months prior to the open water certification phase.
- If my dive buddy is unable to be my caregiver and I require someone else to come on the trip as my caregiver, this will be at my expense. I understand that I can raise additional funds to pay for my caregiver.
- Notify the Dive Pirate staff immediately of any change in my medical condition.
- If my contact information changes, I will let the staff of Dive Pirates know.
Communication*
I will communicate as quickly as possible with my instructor, my chapter, and the Foundation. The best form of communication for me is (please check all that apply):
- Select All
- Phone
- Email
- Text
Out of Pocket Expenses*
I understand there are some out-of-pocket expenses, please acknowledge each expense by checking the boxes
- Passport fees to obtain or renew my passport in time for the trip.
- Airline baggage fees.
- Spending money for travel.
- Nitrox fee, if applicable to my diving situation, approximately $150.
- Tip to the dive staff, approximately $100-$150 per diver.
- Alcoholic drinks, sodas, and any food ordered at the bar at the resort (a buffet is included for each meal during the trip).
- Purchase DAN Medical Dive Accident Insurance (at least the Master plan) or an equivalent policy equal to or greater than this coverage, a minimum of 30 days prior to the trip.
Agreement and Next Steps
PLEASE UPLOAD A PHOTOGRAPH*
- At least one passport-style head and shoulder shot for use in fundraising activities.
- Maximum File Size: 2MB
- File type: .jpg, .jpeg
Drop files here or

Accepted file types: jpg, jpeg, Max. file size: 2 MB.
And finally, please read and check the box for each item.*
- I have read, understand and agree to the Media Release and Privacy Policy.
- I have uploaded a passport-style head and shoulder photo.
- I have read the Statement of Understanding and agree if I am unable to complete any of the above items by the specified timelines I will forfeit my position, my buddy’s position, and my instructor’s position on the Dive Pirates trip and I will be responsible for any fees incurred by Dive Pirates to reschedule. I will have to wait until the next available trip depending on space and other recipients on waiting list.
- 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.
- I have downloaded the Medical Statement and on submission of this application I agree to obtain my physicians sign off within 60 days of the date of application submission.
One last thing, how did you hear about us?
Please check all that apply
- Annual Ball Invitation
- Abilities Expo
- DEMA
- Dive Pirates Brochure
- Email
- Fundraising Event
- Internet Search
- Local Dive Center
- Medical Center/ hospital
- News Feature/ Story/ Article
- Other non-profit
- Previous recipient
- Social Media
- US Department of Veterans Affairs
- Website
- Word of Mouth
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Adaptive Diver Application

Step 1 of 8

Personal

Passport details

Emergency Contact Details

Background

Fundraising

Medical

Sizing for equipment

Media and Privacy Release

Statement of Understanding

Agreement and Next Steps