Become a Warfighter Diver - Warfighter Scuba

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!