Adaptive Diver Registry Form v2

Adaptive Diver Registry Form
To Be Completed By The Adaptive Diver, Parent, or Guardian
- Name*
  
  First NameMiddle NameLast Name
- Birthdate
  
  MonthDayYear
  Date
- Weight (lbs)*
- Height (ft)*
- Height (inches)*
- Shoe Size*
- T-shirt Size*
- Status*
  
  MarriedSingle
- Gender*
  
  MaleFemaleNon-binaryPrefer not to say
- Email*
  example@example.com
- Phone*
  Format: (000) 000-0000.
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Military Affiliation*
  
  NoneActiveVeteranRetired
- Military Branch
  
  Air ForceArmyCoast GuardMarinesNational GuardROTC
- Purple Heart Veteran?*
  
  YesNo
- Ethnicity
- How did you hear about Diveheart?*
  
  0/500
- Name*
- Relationship*
- Email*
  example@example.com
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- 1. Describe your general health and any medical condition which impacts to any extent your activities of daily living andor which you believe may affect your ability to SCUBA dive Date of initial onset of such medical condition*
  
  0/1500
- 2. Describe specifically any physical impairment you may have*
  
  0/1000
- 3. Describe specifically any cognitive psychological and or emotional impairment you may have*
  
  0/1000
- 4. Do you have any indwelling medical devices in your body?*
  
  Baclofen pumpInsulin pumpPacemakerN/A
- 5. Do you currently have any open skin wounds?*
  
  YesNo
- 6. Have you ever had a seizure?*
  
  YesNo
- If Yes, when was the date of your last seizure?
  
  MonthDayYear
  Date
- 7. Are you on any anti-seizure medication?*
  
  YesNo
- When did you stop taking anti-seizure medication?
  
  MonthDayYear
  Date
- 8. Have you ever suffered from autonomic dysreflexia?*
  
  YesNo
- 9. Hearing*
  
  DeafHard of hearingHearing aidN/A
- 10. Vision*
  
  BlindVisually ImpairedGlassesContactsN/A
- 11. Do you use any medical devices related to your condition? (Check all that apply)
  
  Walking caneWalkerWheelchairDrainage Bag(s)
- 12. Prosthetic/Brace
  
  L armR armL legR leg
- Obtain the following information from the most reliable sources available: healthcare providers, parents, guardians, friends, and identify the source of information. If any of the following apply to the adaptive diver, please expand on them in the space provided below
- 1. Triggers: If the adaptive diver has any type of cognitive, psychological, or emotional impairment, please describe what, if anything, upsets or disturbs the individual or causes other emotional stress. (Enter N/A if non applicable to person)*
- 2. Tactile Sensitivity: Is the adaptive diver sensitive to anything touching them? If so, please describe. (Enter N/A if non applicable to person)*
- 3. What calming techniques are most effective should the adaptive diver become emotionally disturbed or upset? (e.g., diverting attention to favored topics, etc.) (Enter N/A if non applicable to person)*
- 4. Is there a health care provider, parent, guardian, friend, or other individual who knows how to address situations that may trigger emotional stress in the adaptive diver? If so, please provide their contact information.
- Name
- Relationship
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Please list any medications you are currently taking what they are for dose and administration regime
- Do you have any allergies?*
  
  YesNo
- Please list allergies
- 1. Can you swim and tread water?*
  
  YesNo
- 2. Can you snorkel?*
  
  YesNo
- 3. Have you ever participated in an Introduction to SCUBA event?*
  
  YesNo
- Date
  
  MonthDayYear
  Date
- Location
- 4. Are you a certified SCUBA diver?*
  
  YesNo
- Agency
- Date
  
  MonthDayYear
  Date
- Cert Level
- 5. Were you a certified SCUBA diver prior to your disability or physical impairment?*
  
  YesNo
- Date of last SCUBA dive
  
  MonthDayYear
  Date
- Total number of dives
- I, {name74} (adaptive diver), have reviewed the above registry information and verify that all the above information is true.
- Print Full Name*
- Date*
  
  MonthDayYear
  Date
- Signature*
- I, [Enter Full Name Below], the natural parent or legal guardian of the above identified adaptive diver, have reviewed the above registry information and verify that all the above information is true.
- Print Full Name
- Date
  
  MonthDayYear
  Date
- Signature
- Should be Empty: