www.DenverDivers.com DENVER DIVER S SNORKELING STUDENT’S NAME: ________________________________________ MALE FEMALE DOB: __________________ MINOR ADDRESS: ___________________________________________________________________ CITY: _________________________________ STATE: ___________ ZIP: ___________ TELEPHONE: _________________________________________ HOME WORK MOBILE E-MAIL: _____________________________________________________________________ PARENT/LEGAL GUARDIAN CONTACT INFORMATION PARENT’S NAME: _______________________________ TELEPHONE: ___________________ GUARDIAN’S NAME: _____________________________ TELEPHONE: ___________________ EMERGENCY CONTACT INFORMATION NAME: _______________________________________ TELEPHONE: ____________________ Snorkeling MEDICAL FORM MEDICAL STATEMENT PARTICIPANT RECORD — CONFIDENTIAL INFORMATION Please read carefully before signing. This is a statement in which you are informed of some potential risks correctly, applying correct techniques, it is relatively safe. When established involved in snorkeling and of the conduct required of you during the safety procedures are not followed, however, there are increased risks. snorkeling program. Your signature on this statement is required for you to To snorkel safely, you should not be extremely overweight or out of participate in the snorkeling program offered by: condition. Snorkeling can be strenuous under certain conditions. Your (INSTRUCTOR)___________________________________________ respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, current cold or and (FACILITY) __________________________________________Denver Dives With Ali, LLC d/b/a Denver Divers congestion, epilepsy, a severe medical problem or is under the influence of located in the city of __________________________________________Denver alcohol or drugs should not snorkel. If you have asthma, heart disease, other and state of _______________________________________________Colorado . chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this Read this statement prior to signing it. You must complete this Medical program, and on a regular basis thereafter upon completion. You will also need Statement, which includes the medical questionnaire section, to enroll in the snorkeling program. If you are a minor, you must have this Statement signed to learn from the instructor the important safety rules regarding snorkeling. by a parent or guardian. If you have any additional questions regarding this Medical Statement or the Snorkeling is an exciting and demanding activity. When performed Medical Questionnaire section, review them with your instructor before signing. MEDICAL QUESTIONNAIRE To the Participant: The purpose of this Medical Questionnaire is to find out if you should be ___ Are you presently taking prescription medications (with the examined by your doctor before participating in a recreational snorkeling exception of birth control or anti-malarial)? program. A positive response to a question does not necessarily disqualify you from snorkeling. A positive response means that there is a preexisting HAVE YOU EVER HAD OR DO YOU CURRENTLY condition that may affect your safety while snorkeling and you must seek the HAVE… advice of your physician prior to engaging in snorkeling activities. ___ Epilepsy, seizures, convulsions or take medications to prevent them? Please answer the following questions on your past or present medical ___ Blackouts or fainting (full/partial loss of consciousness)? history with a YES or NO. If you are not sure, answer YES. If any of ___ Inability to perform moderate exercise (example: walk 1.6 km/one these items apply to you, we must request that you consult with a physician mile within 12 mins.)? prior to participating in snorkeling. ___ Heart disease, heart attack, angina, heart surgery or blood vessel surgery? The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. NOTICE: Electronic Signature Agreement. By typing/placing your name on the signature box, you are signing this Medical Statement electronically. You agree your electronic signature is the legal equivalent of your manual signature. ______________________________________________ __________________ ______________________________________________ __________________ Signature Date Signature of Parent or Guardian Date © 2006 Concept Systems, Inc. ADRO:SSI:Education:Diver:Snorkeling • 3083_0606_SSI_SnrklMedStmnt • REORDER #1512SINGLE-SN First Name Last Name By placing my name here, I agree to be responsible for the content of this page. Privacy Policy This Privacy Policy explains why SSI Training Centers obtain your personal data for the purposes of conducting your training, issuing certifications, administration of your private information and any other necessary specifics regarding the performance of this agreement. We review this Privacy Policy periodically for compliance with changes to the GDPR (General Data Protection Regulation) and other relevant regulations. When necessary, we will update the Policy to comply with new requirements. SSI and SSI Training Centers jointly determine the purpose, scope and delivery of training content, processing, issuing and delivering certifications and administration of your personal data stored in the MySSI system at SSI International GmbH, Johann-Hoellfritsch-Straße 6, 90530 Wendelstein, Germany, Email: [email protected], Tel:+49-9129-9099380. If you have questions or you would like a copy of the Joint Controller Agreement which describes the arrangement above and the safeguards of protecting your personal data, go to the following link: https://my.divessi.com/ssi_dc_joint_controller_agreement, or contact SSI at [email protected]. 1. SSI Authorized Training Center “Data Controller” SSI Training Center Name _______________________________________________________________________________________Denver Dives with Ali, LLC d/b/a Denver Divers Street, PO Box _______________________________________________________________________________________557 Milwaukee Street ZIP Code, City _______________________________________________________________________________________80206, Denver State, Country _______________________________________________________________________________________Colorado, U.S.A. 2. Personal Data “Personal data” is any information relating to an individual person (“data subject”). An identifiable natural person is one who can be identified, directly or indirectly, by reference to information such as a name, identification number, location data, or online identification. Name(s), address(es), telephone number(s), e-mail address(es), user ID(s), credit card number(s), social media account ID(s), login username(s), IP address(es) and GPS data are considered personal data. 3. Processing Your Personal Data SSI International GmbH, SSI Training Centers, your SSI Instructor and other SSI Professionals may all be involved in your training, processing, and delivery of your certification, therefore we need to collect and process the following personal data: • First and Last Name • Gender • Training Center Affiliation • Address, Post Box • Photo • MySSI App Geo Locations • Postcode, City • Language • Medical Information • SSI Master ID • State, Country • Insurance Data (when applicable) • Course Type, Course Progress • Email Address • SSI Professional Number (only for • Telephone Numbers (optional) • Certification Data (Number, Date, Instructor, SSI Professionals) Instructor Number, Number of Certification • Date of Birth Dives, Certification Year) • Quality Assurance Data (for Professionals) NOTE: The personal data we collect is for the sole purpose of delivering training content, processing, issuing and delivering certifications, and administration of your personal data stored in the MySSI system. With your registration in the MySSI system, you will be able to access everything SSI – Digital Training Materials, Digital DiveLog, Certification Cards and more at the SSI website www.divessi.com or on the MySSI mobile app. Additionally, SSI International GmbH (SSI), your SSI Training Center, SSI Instructors and SSI Professionals will have access to your personal data for training and certification purposes. For more information you may go to the SSI Privacy Policy at https://my.divessi.com/myssi_privacy. Here you will learn more about data processing, MySSI, the associated services provided by SSI and how your certification card is automatically processed upon your completion of training. When you initially register at MySSI you will receive an email from SSI with your Username and Password. Additionally, you will be provided a link to the SSI Privacy Policy describing how your personal data will be used. Activation of your MySSI account is mandatory to access your personal profile, training progress, certifications, education level and much more. Upon completion of all academic, pool and open water training, SSI will process your digital certification card information – Your Name, Customer Number (Master ID), SSI Training Center, Certifying Instructor, Year You Started Diving, Level of Experience, Number of Dives, and Issue Date. All this information is accessible through our MySSI account. The described processing is