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 be an adaptive dive buddy.  If you are a veteran, we thank you for your service to our country.

Whether you are already scuba certified and will be undergoing adaptive buddy training or will to learn to dive with us, then we require a signed medical statement by your Medical Doctor (MD) or Doctor of Osteopathy (DO) as in order to qualify for scuba diving training, you must pass a medical qualification (if you already have an in date medical statement i.e. within the last 12 months then please send us a copy, if you don’t then please download and complete the form on this page).  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 condition but you must have your MD or DO sign the form releasing you BEFORE we can begin the program.

If appropriate, please download the medical statement form and instructions 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.

Regarding the MD or DO’s sign-off.

  1. The purpose of the medical questionnaire is to find out your current medical condition prior to participating in any scuba diving program.
  2. A copy of the guidelines for recreational 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 DOunfortunately in this instance a Physicians Assistant (PA) or Nurse Practitioner (NP) is NOT valid.

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 and Photograph/Video Release & Privacy Release 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 on 877-393-3483,