SDI Training Record

Student Info: Personal and Confdential Print Clearly Name: ______Birth Date: ______Last / Family / Surname First / Given Initial Day / Month / Year Diver Address: ______❑ M ❑ F Training City: ______State/Province: ______❑ Single Zip/Postal Code: ______Country: ______❑ Married Record Home Phone: ______Daytime Phone: ______Course: ______Email: Certifcate Date: ______/______/______Occupation: ______Referred by: ______Day / Month / Year ______Emergency Contact: Instructor Name SDI Inst #

Name: ______Name: ______Course: ______Address: ______Address: ______Certifcate Date: ______/______/______Day / Month / Year Relationship: ______Relationship: ______Home Phone: ______Home Phone: ______Instructor Name SDI Inst # Work/Cell Phone: ______Work/Cell Phone: ______Course: ______Certifcate Date: ______/______/______How did you hear about our scuba courses or Have you ever participated in any Day / Month / Year our dive center? ❑ Friend/Family member diving activities? ______❑ Internet ❑ Radio ❑ Newspaper Where ?______Instructor Name SDI Inst # ❑ Yellow Pages ❑ Other ______When ? ______Course: ______What additional SDI courses interest you? Certifcate Date: ______/______/______❑ Advanced Diver ❑ Divemaster Day / Month / Year ❑ Rescue Diver ❑ Assistant Instructor ______Instructor Name SDI Inst # ❑ Master Scuba Diver ❑ Instructor Specialties: Course: ______❑ Advanced Adventure Diver ❑ Equipment Specialist ❑ Underwater Navigation Certifcate Date: ______/______/______❑ Advanced Buoyancy ❑ Full Face Mask Diver ❑ Underwater Photographer Day / Month / Year ❑ Altitude Diver ❑ Ice Diver ❑ Underwater Video ______Instructor Name SDI Inst # ❑ Boat Diver ❑ Marine Ecosystems Awareness ❑ VIP ❑ Computer Diver ❑ Night/ Limited Visibility Diver ❑ Wreck Diver Course: ______❑ Computer Nitrox Diver ❑ Research Diver ______Certifcate Date: ______/______/______❑ Deep Diver ❑ Search & Recovery Diver Day / Month / Year ❑ Drift Diver ❑ Shore/Beach Diver ❑ TDI ______Instructor Name SDI Inst # ❑ DPV Diver ❑ Solo Diver ❑ ERDI ❑ Dry Suit Diver ❑ Underwater Hunter & Collector Course: ______What dive destinations interest you? Certifcate Date: ______/______/______❑ Australia ❑ Bahamas ❑ Bermuda ❑ Canada ❑ Caribbean ❑ Florida Day / Month / Year ❑ Hawaii ❑ Mexico ❑ Micronesia ❑ New Zealand ❑ Red Sea ______

❑ US East Coast ❑ US West Coast ❑ Other______Instructor Name SDI Instr #

item#: 210200-01 v.1120 © International Training 1999 , 2012 , 1999 Training International © v.1120 210200-01 item#:

Day / Month / Year / Month / Day

STUDENT SIGNATURE:______DATE: ______/ ______/ ______/ ______/ DATE: SIGNATURE:______STUDENT

student recognizes the need for additional training in order to dive under any other circumstances and after periods of diving inactivity. inactivity. diving of periods after and circumstances other any under dive to order in training additional for need the recognizes student activities without the direct supervision of an instructor, provided the area and conditions approximate those in which the diver was trained. In addition, the the addition, In trained. was diver the which in those approximate conditions and area the provided instructor, an of supervision direct the without activities

210200-01

lled by the student. As indicated by the signature below, the student is mentally and physically prepared to engage in open water diving diving water open in engage to prepared physically and mentally is student the below, signature the by indicated As student. the by lled f ful successfully been

STUDENT LETTER OF AGREEMENT: OF LETTER STUDENT ned and open water requirements for this SDI diver course have have course diver SDI this for requirements water open and ned f con academic, the of all that agrees student The

cation card until the diver receives their permanent open water c-card. c-card. water open permanent their receives diver the until card cation f certi water open temporary a only is This dated. and

ed open water diver. This signed form is only is form signed This diver. water open ed f certi a considered is student The VALID FOR 30 DAYS 30 FOR VALID from the last OW dive that the evaluating instructor signed signed instructor evaluating the that dive OW last the from

BOTH INSTRUCTOR SIGNATURES ARE PRESENT ON THIS FORM THIS ON PRESENT ARE SIGNATURES INSTRUCTOR BOTH cation as a SDI Open Water Scuba Diver have been met - If - met been have Diver Scuba Water Open SDI a as cation f certi for requirements All

Day / Month / Year / Month / Day Day / Month / Year / Month / Day

Signature: ______Date:_____/_____/______Date:_____/_____/______Signature: Signature: ______Date:_____/_____/______Date:_____/_____/______Signature:

the Skills and Open Water requirements. Water Open and Skills the

Instructor 1 Instructor

Instructor 2 Instructor

ned Water requirements. Water ned f Con and Academic

The student above has completed all all completed has above student The

The student above has completed all the the all completed has above student The Phone: ______Fax or E-mail:______or Fax ______Phone:

Phone: ______Fax or E-mail:______or Fax ______Phone: Training Agency: ______Facility Name:______Facility ______Agency: Training

Instr. #______Facility Name:______Facility #______Instr. Instructor Name: ______Instr. #______Instr. ______Name: Instructor

Instructor Name: ______Name: Instructor

Day / Month / Year / Month / Day

ned Water/ Academic Instructor Instructor Academic Water/ ned f Con Date:_____/_____/______Open Water/ Evaluating Instructor Instructor Evaluating Water/ Open Date:_____/_____/______

Conﬁned Water Sessions Water Conﬁned ____ /____/______OW Session 5* ____ /____/______5* Session OW ______(* ______Dive) Dive) Optional

Float Test 10 Minute Survival Float Survival Minute 10 Test Float OW Session 4 4 Session OW ______/____/______

OW Session 3 ____ /____/______3 Session OW ______/____/______

OW Session 2 2 Session OW ______/____/______Swim Test 200 meters or 300 meters snorkel meters 300 or meters 200 Test Swim

OW Session 1 1 Session OW ______/____/______CW Session 5* ____ /____/______5* Session CW ______(* ______) ) Optional

Initials Initials Initials dd/mm/yy) ( ____ /____/______4 Session CW ______

Date Completed Student Instructor Comments Instructor Student Completed Date CW Session 3 ____ /____/______3 Session CW ______

__Demonstrate 2 types of entries of types 2 __Demonstrate __Cramp Relief __Cramp ____ /____/______2 Session CW ______

Entries __Tired Diver Tow Diver __Tired ____ /____/______1 Session CW ______

ation f In Oral & __Auto Rescue Techniques Rescue (dd/mm/yy) Initials Initials Initials (dd/mm/yy)

BCD __Swimming Ascent __Swimming

Date Completed Student Instructor Comments Instructor Student Completed Date

__Partial & Full & __Partial making a controlled ascent controlled a making

Mask Clear Mask while Buddy with Air __Share Day / Month / Year / Month / Day

Open Water Sessions

This student completed the SDI eLearning course: course: eLearning SDI the completed student This -OR- ____ /____/______❑ ❑ Academic Sessions __Clearing & Recovery & __Clearing __Alternate Air Source Air __Alternate

Regulator Use Regulator Out of Air Emergencies Air of Out ____ /____/______5 Chapter ______

__Reading & Understanding Gauges Understanding & __Reading __Removal & Replacement & __Removal ____ /____/______4 Chapter ______

Computer Use Computer Weight System Adjustment System Weight

____ /____/______3 Chapter ______

__Underwater Communication __Underwater __Controlled Descents __Controlled

____ /____/______2 Chapter ______

__Self & Buddy & __Self __Controlled Ascents __Controlled

____ /____/______1 Chapter ______

Pre Dive Check Dive Pre __Hovering

Completed (dd/mm/yy) Completed Initials Initials

__Assembly & Disassembly & __Assembly __Fin Pivot __Fin

Knowledge Review Student Instructor Comments Instructor Student Review Knowledge

Scuba System Scuba Buoyancy Control Buoyancy

Skill Performance Record for the Global Referral: Global the for Record Performance Skill

Day / Month / Year / Month / Day

Birth Date: ______/______/______Date: Birth ______Age: ____F Sex:____M for your records. your for

Info Student

form this of copy a retain and student, the to form referral original this Give __ E-mail: ______E-mail: ______Fax:

Sign this global referral form. referral global this Sign __

Phone: ______Phone: ______Country:

and Initial all the required open water skill and dives listed on this form. this on listed dives and skill water open required the all Initial Evaluate __

State: ______Zip: ______Zip: ______State: ______City:

Have referring student sign your facility’s waiver and release form. release and waiver facility’s your sign student referring Have __

Address: ______Address: Review students’ medical history form. history medical students’ Review __

Name: ______Name: Active Instructor Active with an internationally recognized training agency. agency. training recognized internationally an with an Be __

SDI Open Water Diver Record and Global Referral Form Referral Global and Record Diver Water Open SDI Open Water / Evaluating Instructor MUST: MUST: Instructor Evaluating / Water Open Name ______Daytime Phone______Cell Phone ______(Print) Last / Family / Surname First / Given Initial

o o o o o o o o o o o o o o o o o o o o o o o o o AND No No No No No No No No No No No No No No No No No No No No No No No No No * * * * * * * * * * * * * * * * * * o o o o o o o o o o o o o o o o o o o o o o o o o Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Go To Box F Box To Go Go To Box B Box To Go Go To Box C Box To Go Go To Box E Box To Go Go To Box D Box To Go Go To Box A Box To Go Go To Box G Box To Go for a medical evaluation. Participation in a diving course course diving a in Participation evaluation. medical a for .

do not dive Box E – I have/have had: E – I have/have Box requiring problems or psychological health, mental Behavioral treatment. medical/psychiatric Recurrent back problems in the last 6 months that limit my everyday everyday limit my that in the last 6 months back problems Recurrent activity. Major depression, suicidal ideation, panic attacks, uncontrolled uncontrolled panic attacks, suicidal ideation, Major depression, treatment. medication/psychiatric requiring bipolar disorder or a learning/ health condition with a mental Been diagnosed ongoing care. requires that disorder developmental within the last 5 treatment addiction requiring An drugs or alcohol to years. had: F – I have/have Box Back or spinal surgery within the last 12 months. within the diabetes OR gestational drug- or diet-controlled, Diabetes, last 12 months. abilities. physical limits my hernia that uncorrected An surgery or ulcer within wounds, problem ulcers, or untreated Active the last 6 months. had: G – I have Box swim or to medical clearance surgery and do not have Ostomy activity. engage in physical Dehydration requiring medical intervention medical within the last 7 days. requiring Dehydration surgery or ulcer ulcers or intestinal stomach or untreated Active within the last 6 months. fux disease re or gastroesophageal heartburn, regurgitation, Frequent (GERD). disease. or Crohn’s colitis ulcerative or uncontrolled Active Bariatric surgery within the last 12 months.

o o o o o o o o o o o o o o o o o o No No No No No No No No No No No No No No No No No No * * * * * * * * * * * * * * * * * * o o o o o o o o o o o o o o o o o o Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

the questions in boxes A - G below, please by signing and and to read the above the dating A agree statement it questions - in G boxes below, nstructor Name (Print) Facility Name (Print) Facility nstructor Name (Print) articipant Birthdate (dd/mm/yyyy) Name (Print) to any of to any I am over 45 years of age. 45 years I am over kilometer/one 1.6 or walk mile in 14 minutes example, (for exercise performI struggle to moderate participate been unable to physical in a normal OR I have without resting), swim 200 meters/yards activity within the past 12 months. ftness or health reasons due to or nasal passages/sinuses. ears, eyes, with my had problems I have past surgery. to related ongoing problems OR I have surgery had last 12 months, within the I have er from f or su head injury, fcant signi stroke, seizures, headaches, had migraine lost consciousness, I have injury neurologic or disease. persistent for years) the last fve within treatment required have (or treatment undergoing I am currently I or, or an addiction drugs or alcohol; to panic attacks, personality disorder, problems, psychological with a learning disability. diagnosed been have or diabetes. hernia, ulcers, had back problems, I have diarrhea. including recent problems, or intestine stomach had I have of birth than or anti-malarial drugs other I am taking control the exception (with medications prescription mefoquine (Lariam). I have had problems with my lungs/breathing, heart, blood, or have been diagnosed with COVID-19. with been diagnosed heart, or have blood, lungs/breathing, with my had problems I have

OR 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. Directions Complete this questionnaire as a prerequisite to a recreational scuba diving pregnant, become to or attempting pregnant, If are you or freediving course. Note to women: P I .

I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered answered have may I questions any from resulting consequences any for responsibility accept I that understand and honestly, questions all answered have I

to questions 3, 5 or 10 above

to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it. and dating signing by the participant below to statement and agree read Please is not required. a medical evaluation all 10 questions above, to YES A diagnosis of COVID-19. A diagnosis of age AND: 45 years B – I am over Box other means. by smoke or inhale nicotine I currently level. a high cholesterol I have high blood pressure. I have disease or die suddenly or of cardiac had a close blood relative I have a family history the age of 50, OR have of heart before disease stroke age 50 (including abnormal heart coronary arterybefore rhythms, disease or cardiomyopathy). had: C – I have/have Box Sinus surgery within the last 6 months. balance. with or problems hearing loss, Ear disease or ear surgery, sinusitis within the past 12 months. Recurrent surgery within the past 3 months. Eye had: D – I have/have Box Head injury within the past 5 years. with loss of consciousness injury neurologic or disease. Persistent or take Recurring headaches within the past 12 months, migraine them. prevent to medications (full/partialBlackouts or fainting within the last loss of consciousness) 5 years. prevent to OR take medications or convulsions, seizures, Epilepsy, them. Box A – I have/have had: A – I have/have Box placement, stent heart heart surgery, Chest surgery, surgery, valve lung). (collapsed or a pneumothorax airways or congested fever hay allergies, severe wheezing, Asthma, activity/exercise. physical limits my that within the last 12 months heart my chest pain on such as: angina, or illness involving A problem exertion, heart immersion pulmonary failure, edema, heart or attack heart any OR am taking condition. for medication stroke, within the past 12 coughing and currently bronchitis Recurrent with emphysema. been diagnosed OR have months, Diver Medical | Medical Diver Participant Questionnaire Recreational scuba requires diving good physical and There are and a few freediving medical conditions mental which can health. be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant seek should you if determine to basis a provides Questionnaire out that evaluation. If this you on represented have not ftness any diving your concerns about diving. before physician with your consult form, you think you If diving. avoid ill, feeling are you If yourself protect disease, contagious a have may and others by not participating in dive training and/or dive on activities. References “diving” to this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, questions honestly. answer all Participant Signature NO answered If you Statement: Participant or past health conditions. existing disclose any to failure my or for inaccurately (dd/mm/yyyy) Date required.) signature parent/guardian participant‘s if a minor, (or, Signature Participant * If answered you physician your to Form) Evaluation Physician’s the and Questionnaire (Participant form this of pages three all take approval physician’s your requires

Student Info: Personal and Confdential Print Clearly - - - - Name: ______Birth Date: ______- - - Last / Family / Surname First / Given Initial Day / Month / Year Diver Address: ______❑ M ❑ F Training City: ______State/Province: ______❑ Single Zip/Postal Code: ______Country: ______❑ Married Record Home Phone: ______Daytime Phone: ______Course: ______Email: Certifcate Date: ______/______/______Occupation: ______Referred by: ______Day / Month / Year 877.436.7096 fax ______· Emergency Contact: Instructor Name SDI Inst #

Name: ______Name: ______Course: ______Address: ______Address: ______Certifcate Date: ______/______/______

______or Guardian of Parent Signature applicable) (where Day / Month / Year Relationship: ______Relationship: ______Home Phone: ______Home Phone: ______Instructor Name SDI Inst #

Work/Cell Phone: ______Work/Cell Phone: ______888.778.9073 phone · Course: ______) training program under sanction under SDI. through program ) training Certifcate Date: ______/______/______How did you hear about our scuba courses or Have you ever participated in any Day / Month / Year

our dive center? ❑ Friend/Family member diving activities? ______Year / Month / Day Day / Month / Year / Month / Day ❑ Internet ❑ Radio ❑ Newspaper Where ?______Instructor Name SDI Inst #

specify course ❑ Yellow Pages ❑ Other ______When ? ______Course: ______What additional SDI courses interest you? Certifcate Date: ______/______/______❑ Advanced Diver ❑ Divemaster Day / Month / Year ❑ Rescue Diver ❑ Assistant Instructor ______Instructor Name SDI Inst # ❑ Master Scuba Diver ❑ Instructor [email protected] tdisdi.com Specialties: Course: ______

❑ Advanced Adventure Diver ❑ Equipment Specialist ❑ Underwater Navigation Certifcate Date: ______/______/______Stuart, FL 34994 1321 SE Decker Ave., · ❑ Advanced Buoyancy ❑ Full Face Mask Diver ❑ Underwater Photographer Day / Month / Year No alterations, changes, omissions or revisions may be made. made. be may revisions or omissions changes, alterations, No

❑ Altitude DiverFill in and initial each paragraph before signing at the bottom. ❑ Ice Diver ❑ Underwater Video ______Instructor Name SDI Inst # ❑ Boat Diver ❑ Marine Ecosystems Awareness ❑ VIP ❑ Computer Diver ❑ Night/ Limited Visibility Diver ❑ Wreck Diver Course: ______Please read carefully. If any questions arise, ask your instructor before signing. signing. before instructor your ask arise, questions any If carefully. read Please ❑ Computer Nitrox Diver ❑ Research Diver ______Certifcate Date: ______/______/______❑ Deep Diver ❑ Search & Recovery Diver Day / Month / Year

❑ Drift Diver ❑ Shore/Beach Diver ❑ TDI ______International. Diving Scuba by sanction under taught courses all for required is document This Instructor Name SDI Inst # ❑ DPV Diver ❑ Solo Diver ❑ ERDI Contact: Scuba Diving Int’l or unenforceable provision or provisions had never been contained herein. been contained had never or provisions provision or unenforceable I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. own my of document this signed have I that and recital, mere a not and contractual any are for herein terms the agreement, that this of understand I provisions the of more or one that event the in that, agree and understand I that Further act. free reason, illegal is held by ainvalid, court such if as of competent construed be jurisdictionshall agreement this to and be invalid or unenforceablehereof, provision in any other respect, any ect f a suchnot invalidity,shall illegality orunenforceability that I expressly assume the risk of said injuries and that I will not hold the above listed individuals or companies responsible companies or individuals listed above the hold not will I that and injuries said of risk the assume expressly I that for the same, and I and hold agree to said harmless indemnify, course and defend, for Parties Released any such injuries me. by incurred from. ascent gas) breathing (without free a execute safely to able am I than deeper me place activitiesmay these that understand I and condition operating its for responsible am I that and equipment own furnish my to required be may I that understand I maintenance. I further agree to save, defend, indemnify, and hold harmless said course and Released Parties from any claim or lawsuit by by lawsuit or claim any from Parties Released and course said harmless hold and indemnify, defend, save, to agree further I heirs arising or directlyassigns, estate, or indirectly purporting out enroll of my anyone family, me, my to act behalf, on my certi even my fcation participationand or afterment arising claims receive both I including during the course course this in false or fraudulent. be groundless, if such claims may etc. drowning, I also understand that diving narcosis, activities gas are inert physically strenuous and that I will be toxicity, exerting myself during oxygen this diving course, hyperventilation, panic, attack, heart of result a as injured am I if that and sible in anyway for any injury, death, or other damages to me or my family, heirs, or assigns that may occur as a result of my my of result a as occur may that assigns or heirs, family, my or me to passive damages whether other or death, Parties, injury, Released any the for anyway including in sible party, any of negligence the of result a as or class diving this in participation or active. course, said with connection in risks all assume personally hereby I course, this in enroll to allowed being of consideration In for any harm, injury, or damage that may befall or unforeseen. whether foreseen nected therewith, me while I am enrolled as a student of this course, including all risks con both, from such a recompression chamber. I both, from still chamber. such choose to a with dives in proceed such recompression instructional spite of the possible site. the dive to chamber in proximity of a recompression absence instructor(s)______, neither my that I understand and agree ______, employ instruction, companies, my liated f a received I which shareholders, through directors, facility the cers, f o the nor International, Diving Scuba and Training International ees, agents, or assigns of respon the or liable above held listed be entities may and/or Parties”) individuals, “Released nor the as authors to of referred any (hereinafter materials certi fcation including and textstraining for and used expressly tables Further, I understand that diving with compressed air, oxygen enriched air (nitrox) involves certain inherent risks including including risks inherent certain involves (nitrox) air enriched oxygen air, compressed with diving that baric I understand Further, barotrauma/hyper other or injuries life marine narcosis, gas inert trips, diving toxicity, water oxygen open embolism, the that sickness, understand decompression further I chamber. recompression a in treatment require that occur can injuries which are necessary for training and certi fcation, may be conducted at a site that is remote, either by time of distance or Witness Date Witness ❑ Dry Suit Diver ❑ Underwater Hunter & Collector Course: ______Date of Student/Participant Signature

What dive destinations interest you? Certifcate Date: ______/______/______❑ Australia ❑ Bahamas ❑ Bermuda ❑ Canada ❑ Caribbean ❑ Florida Day / Month / Year

______RECTLY OR INDIRECTLY, INCLUDING, BUT THE NOT OR RECTLY NEGLIGENCE LIMITED TO, INDIRECTLY, OF THE WHETHER RELEASED PASSIVE PARTIES, OF ASSUMPTION EXPRESS AND RELEASE LIABILITY THIS OF CONTENTS THE OF MYSELF INFORMED FULLY I HAVE OR ACTIVE. AND MY HEIRS. READING IT BEFORE SIGNING IT ON BEHALF OF MYSELF RISK BY AGENCY______AND INTERNATIONAL TRAINING, AND SCUBA DIVING INTERNATIONAL, AND TRAINING, AND SCUBA DIVING INTERNATIONAL, AND INTERNATIONAL AGENCY______ENTITIES ALL AND AS OTHER RELATED RELEASED DEFINED PARTIES ABOVE, FROM ALL LIABILITY OR RESPONSIBILITYWHAT SOEVER FOR PERSONAL PROPERTYINJURY, DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, OR ARISING OUT OF, DI IT THE IS INTENTION OF ______THIS BY TO INSTRUMENT EXEMPT AND RELEASE MY IN (AND OTHERS,______), STRUCTORS, ______THE THROUGH FACILITY WHICH I RECEIVED MY INSTRUCTION THE ______, TRAINING ______of scuba diving activities of scuba _____ rm that I have been advised and thoroughly informed of the inherent hazards hazards inherent the of informed thoroughly and advised been have I that rm f a hereby ______, I, For ______( can form) on this be listed ONE course (Only GENERAL OF RISK ASSUMPTION AND EXPRESS RELEASE LIABILITY ❑ Hawaii ❑ Mexico ❑ Micronesia ❑ New Zealand ❑ Red Sea ______