Become a Warfighter Diver!

PURPLE HEART/FOREIGN EQUIVALENT REQUIRED TO QUALIFY FOR OUR PROGRAMS

Please fill out the form completely and honestly. Upload any military records to prove service. Any medical documentation you feel necessary please upload as well as this will be required after vetting. Please black out any sensitive personal information before uploading. We are not responsible for this. Thank you.

Please download the SSI Medical Forms by clicking the PDF icon below and fill them out. Scan them and attach them with your other medical documentation required in the form below.

Step 1 of 4 - Personal Info

Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Closest Airport to Fly From*
If you know the three digit designator please add that as well.
Height*
feet and inches
Weight*
in pounds (lb)
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female

Medical Information
SCUBA diving is an adventure sport and is not suitable for all individuals and/or medical conditions. Please have the attached medical releases completed by a physician (MD) from the VA or civilian physician. A dive medicine or hyperbaric doctor is preferred but not required. Note: The primary instructor reserves the right to refuse admittance to any applicant with a medical condition they feel is an unacceptable risk for SCUBA diving. Answer each question on the attached medical clearances/releases with full words of YES or NO. Please provide a copy of all of your current medication from your physician or from the VA website at https://www.myhealth.va.gov/index.html
Injuries (Check ALL that Apply)*
Hold the cntrl or cmd key while selecting to select multiple injuries
Paraplegic – Level of injury (T7 etc)*
Please describe
Complete Quadriplegic - Level of injury (C4 etc)*
Please describe
Incomplete Quadriplegic- Level of injury (C6-7 etc)*
Please describe
Other illness or condition not listed above*
Please describe
*Explain any items marked with a * above*

Become a Warfighter Diver!

PURPLE HEART/FOREIGN EQUIVALENT REQUIRED TO QUALIFY FOR OUR PROGRAMS

Step 1 of 4 - Personal Info

Eligibility Information

Medical Information

Scuba Experience

Multi-Limb Amputee*
Amputee above knee L Leg
Amputee above knee R Leg
Amputee below knee L Leg
Amputee below knee R Leg
Deaf Hard of Hearing
Blind/Vision Impaired
Poly-Trauma
TBI
PTSD
Amputee above elbow L Arm
Amputee above elbow R Arm
Amputee below elbow L Arm
Amputee below elbow R Arm
Loss of sensory response*
Thermal regulation issue
Speech Impairment*
Developed decubiti
Hemiplegic on L Side
Hemiplegic on R Side
Impaired Cough Reflex
COPD
Paraplegic – Level of injury (T7 etc)
Complete Quadriplegic - Level of injury (C4 etc)
Incomplete Quadriplegic- Level of injury (C6-7 etc)
Intermittent Catheter
Indwelling Catheter
External Catheter
History of Hyperreflexia (Autonomic Dysreflexia)
Orthostatic Hypo-tension (low Blood pressure)
Unable to perspire in any area of the body
Other illness or condition not listed above