Adaptive Diver Application

- 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:
Passport details
Do you have a valid passport?*
- No
- Yes
Expiration date*
Date Format: MM slash DD slash YYYY
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

Save and Continue Later

Emergency Contact Details
Emergency Contact Details*
First Last
Emergency Phone*
Emergency Email

Save and Continue Later

Background
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?
Date Format: MM slash DD slash YYYY
Highest rank held?*
Date joined Law Enforcement:*
Date Format: MM slash DD slash YYYY
Leaving date:
Please leave blank if still employed.
Date Format: MM slash DD slash YYYY
Date joined First Responder Unit*
Date Format: MM slash DD slash YYYY
Leaving date:
Please leave blank if still employed.
Date Format: MM slash DD slash YYYY
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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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.

Save and Continue Later

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

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

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