NPLB Veteran Registration Form

Veteran Application

Thank you for your service and sacrifice! If you are interested in, or have been selected to attend a trip or event, please fill out the form below. Be sure to check each of your answers for accuracy. Your information will be kept confidential and safeguarded.
Which event are you hoping to attend?
If unknown, type "unspecified"
How did you hear about us?
Name*

First NameMiddle InitialLast Name
Prefer to be called:
Name
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Phone Number:*
E-mail*
example: mike@yahoo.com
Shirt Size?*
Is the event you are hoping to attend in your area?*

I can drive and don't need a hotelI can drive but will still need a hotelI need to fly and need a hotelOther
Preferred Departure Airport:
Alternate Departure Airport:
Gender
TSA PreCheck #
Example: 218321953
Military Status*
Service Branch*
Rank*
Purple Heart Recipient?*

YesNo
Theater of Operation (Check all that apply)

OIFOEFONDGulf WarVietnamOther
Disability Rating (If applicable)
Briefly describe your injuries.*
List any physical restrictions or special needs including diet restrictions.*
Will you have a service/companion dog with you during the event?*

YesNo
Note that some trips/events may not be conducive to service animals.
Are you hoping to attend a SCUBA trip?*

YesNo
Are you SCUBA certified? If yes, please attach a copy of your certification card below.*

YesNo
If you are SCUBA certified, briefly describe you SCUBA experience. When and where was your last dive after being wounded or injured?
Do you need SCUBA equipment?
(BC, reg, mask, fins, snorkel?)
Shoe size
(e.g., 23)
If bringing a spouse or caregiver, is he/she a certified SCUBA diver?*
While we make every attempt to include SCUBA certified spouses on dives, the veteran participation takes priority. Spouses participate on a space available basis.
If you are bringing any children, please list names, ages and genders.
List any dietary allergies or restrictions for you and any of your guests*
Have you ever attended a CWVC or NPLB dive?*

YesNo
If yes, please list date, location and type
Have you attended retreats or challenges with any other veteran or civilian organization?*

YesNo
If yes, please list date, location and type of event
Please describe how your family would benefit from a SCUBA challenge*
Do you have a form of DoD identification for entry onto Naval Air Station Key West? (if no, SECNAV 5512/1 will be sent for access).*

YesNo
Upload DoD photo ID (or driver's license if no DoD ID)*

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Upload your SCUBA certification card(s) here

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Upload any other supporting documents

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In case of emergency...
Do you have personal health and medical insurance? (required as a condition for SCUBA Challenge participation. If yes, please ensure your current coverage will include SCUBA and will be in effect during the trip.*

YesNo
Are you a member of the Divers Alert Network? (www.dan.org)*

YesNo
Are you currently taking any medications?*

YesNo
Please list them here:
Emergency Contact:*

First NameLast Name
Relationship
Example: Spouse
Phone Number*
E-mail*
example: mike@yahoo.com
Medical Information

All information on this form is held confidentially and provides us with helpful information to assist in selection of and to ensure a successful experience for all participants. The undersigned understands that SCUBA diving is inherently dangerous and physically demanding. Therefore, participants must be without significant neurological, pulmonary, or respiratory issues, and be physically and mentally fit. The following questions are taken from the National Association of Underwater Instructors (NAUI) Medical Evaluation Checklist. Please check "Yes" or "No" to each question and provide details for any "Yes" responses in the Notes section.
HIPAA Release

I understand and agree I could sustain a medical emergency while attending the event, and such medical emergency might relate to my current health status. I understand that sharing my health information is to ensure NPLB/CWVC event personnel are aware of my health-related matters in case I am involved in a medical emergency during the event. I authorize NPLB and CWVC to disclose my health information to event personnel, including personnel from NPLB/CWVC or other organizations/individuals involved in running the event. I authorize NPLB to disclose my medical data and information for the reasons described above, and release NPLB from any liability for disclosure under state and federal law. This HIPAA authorization and release shall be effective and valid from the date this application is executed and shall not expire. I understand that I am permitted to revoke this authorization and release. I understand, however, that it may be too late to revoke the authorization granted by me in this HIPAA release form if the information was already disclosed to event personnel.
Behavioral Health*

YesNo
Bronchitis*

YesNo
Contact Lenses*

YesNo
Claustrophobia*

YesNo
Tuberculosis*

YesNo
Dental Plates*

YesNo
Agoraphobia*

YesNo
Respiratory Problems*

YesNo
Physical Disability*

YesNo
Migraine Headaches*

YesNo
Back Problems*

YesNo
Serious Injury*

YesNo
Epilepsy*

YesNo
Back/Spinal Surgery*

YesNo
Over 40 Years Old*

YesNo
Ear or Hearing Problems*

YesNo
Diabetes*

YesNo
Hepatitis*

YesNo
Trouble Equalizing Sinus Pressure*

YesNo
Sinus Trouble*

YesNo
Ulcers*

YesNo
Colostomy*

YesNo
Drug Allergies*

YesNo
Severe Hay Fever*

YesNo
Hernia*

YesNo
Alcohol or Drug Abuse*

YesNo
Cardiac Issues*

YesNo
Dizziness or Fainting*

YesNo
Restricted from any Activity*

YesNo
High Blood Pressure*

YesNo
Angina*

YesNo
Hospitalized*

YesNo
Heart Surgery*

YesNo
Pregnant*

Currently PregnantPregnant in the pastNo
Asthma*

YesNo
Motion Sickness*

YesNo
Recent Surgery*

YesNo
Please provide additional information for any "Yes" answers
TRIP RELEASE FORM ACKNOWLEDGEMENT

If you are selected to attend the SCUBA Challenge and are not certified, you will be required to obtain written clearance to SCUBA dive from a physician and forward that clearance to NPLB prior to the event.   If you are a certified diver and answered “Yes” to any of the medical questions listed above, NPLB reserves the right to require you to obtain clearance to SCUBA dive from a physician. NPLB/CWVC Physicians will make such determinations after reviewing responses to the medical questions.

TRIP RELEASE FORM ACKNOWLEDGEMENT

The Undersigned affirms all statements contained in this application are true and correct and understand that false or inaccurate information in the application is grounds to deny application, rescind invitation, or revoke further support.

By executing this application, the Undersigned releases and holds harmless, and forever discharges, NPLB Outdoors, its directors, officers, volunteers, subcontractors, agents, and staff from all claims and causes of action of every kind or nature, foreseen and unforeseen, arising from or in any way connected with NPLB, this application, or any SCUBA event. The Undersigned further understands and agrees that the foregoing release is legally binding.

If selected to participate in the event, NPLB Outdoors will supply additional releases and waivers to each attendee for execution. Such documents may be supplied electronically or at the beginning of the event. The undersigned understands execution of such documents is mandatory to attend and participate in the event. Such documentation will include:

o   A comprehensive release and waiver by attendee for injury, death, and/or property damages.

o   A copyright assignment for photos and videos taken by attendee during the event;

o   A privacy and publicity release permitting CWVC to publish pictures/video of attendee;

o   A release and waiver required by dive vessels;

o   A HIPPA medical information release and waiver;

o   Medical research surveys; and

o   Other possible documentation.

The Undersigned recognizes that every effort will be made to obtain handicap accessible accommodations on Key West military installations during the event. However, there are instances where this may not be feasible. Under such circumstances, CWVC may utilize non-handicap accessible accommodations.

The Undersigned executes this application as of the date written below.
Are you hoping to attend a hunting or fishing trip?*

YesNo
Do you currently have an active hunting license with all necessary stamps and endorsements for the state the event is in?

YesNo
Have you ever had a hunting license?*

YesNo
Please provide your DNR ID# and issuing state: *
Example: 483952 (MD)
Have you completed a hunters safety course?*

YesNo
Please provide your card # and date: *
Example: 535912 (10/15/2006)
Full MOS # as shown on your DD214: *
Example: 12B30
Last four of your Social Security #:*
Drivers License #*
Example: K-364-589-147-682
Issuing State:*
Example: Maryland
Note that some trips/events may not be conducive to having an accompanying caregiver. Each guest must submit an event release form.
Will you have a guest or caretaker with you?*

YesNo
Guest's Name*

First NameLast NameRelationship
Guest Contact Number:

Area CodePhone Number
E-mail
example: mike@yahoo.com
Date of Birth*

MonthDayYear
Gender*
Will your guest be flying as well?*

YesNo
Preferred Departure Airport:*
Alternate Departure Airport:
TSA PreCheck #
Example: 218321953
Will you have any other guests with you?*

YesNo
Third person

First NameLast NameRelationship
Fourth person

First NameLast NameRelationship
Active Duty Unit
Active Duty Commanding Officer
Duty Phone #
Upload DD214*

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Upload VA Rating Letter (If Applicable)

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Carefully read and sign the section below

TRIP RELEASE FORM:

The undersigned acknowledges that his/her participation in a retreat or an event involves certain inherent risks of physical injury, illness and/or loss of personal property.

The undersigned also affirms all statements contained in this application are true and correct and understand that false or inaccurate information will be the basis for denial and/or revocation for all support provided by Operation NPLB Outdoors.

The undersigned by his/her execution of this trip release form hereby releases and holds harmless and forever discharges Operation NPLB Outdoors and its officers, employees, directors, agents, volunteers, property owners, and staff from any and all claims, causes of action of whatsoever kind of nature, foreseen or unforeseen, arising from or in any way connected with a retreat or event.

The undersigned further recognizes that if not for his/her execution of this release form, Operation NPLB Outdoors would not permit participation in a retreat or event.

The undersigned grants permission to use his/her image on photographs and/or video taken at NPLB Outdoors events in publications, news releases, online and in other communications related to the mission of NPLB Outdoors, at the discretion of NPLB Outdoors and without payment or other consideration.

The undersigned further certifies that he/she is an adult and has read the above information carefully before his/her execution of same and that he/she fully understands its terms.
I consent to receive communication by text message specifically related to event participation

YesNo
Signature*
Name

First NameLast Name
Should be Empty:

Veteran Application

Medical Information

HIPAA Release