Fillable Try Scuba and Basic Diver Participant Registration Form (Rain Retail POS)

Fill Online, Printable, Fillable, Blank Try Scuba and Basic Diver Participant Registration Form (Rain Retail POS) Form

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Try Scuba and Basic Diver Participant Registration Form (Rain Retail POS)

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The Try Scuba and Basic Diver Participant Registration Form (Rain Retail POS) form is 7 pages long and contains:

  • 1 signature
  • 14 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

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© SSI International GmbH | TR-REGISTRATION-BD_English-Metric | 11052019
Try Scuba and Basic Diver Participant Registration Form
First Name Last Name Date of Birth (DD/MM/YY)
Mailing Address
Email Address Cell Phone
Emergency Contact
Name
Email Address
Relationship
Cell Phone
Download the free MySSI App, available for iOS or Android! SSI designed the MySSI App to be that “All-In-One Tool” for your diving experiences
and to give you access to your Digital Learning Materials, Digital Logbook and Digital Recognition Cards, all in the palm of your hand. There
are a variety of features like news, local events, training dates, fun 360º videos and even dive tables and hand signals to review before your
next dive.
my.divessi.com MySSI App: iOS MySSI App: Android
Instructor Name: _______________________
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© SSI International GmbH | TR-INTRO-FIT_English-Metric | 10182019
SSI Introductory Scuba Experience - Fit To Dive Screening
Scuba diving is an adventurous and exciting activity, but it can also be strenuous and potentially dangerous. As with any aquatic adventure,
especially those relying on underwater breathing equipment, there are inherent dangers which cannot be eliminated that may cause serious
illness, injury or death. You must be in good health to dive. If you have any questions about your medical, mental or physical tness to dive,
you should consult a physician to assess your individual risk factors.
This form is to help you determine if you should be examined by a physician. If you have any doubt about your tness to dive, then you must
obtain approval from a physician prior to diving. Failure to obtain a physician’s approval to dive may signicantly increase your risk of illness,
injury or death. You are solely responsible for honestly evaluating your tness to dive and you are ultimately responsible for your safety and
wellbeing when engaged in dive activities (including boat travel, putting on/taking o dive equipment, getting in and out of the water,
etcetera).
Answer each of the following questions about your past and present medical conditions by lling in the corresponding [NO] or [YES] box.
If you are not sure, then answer [YES]. A [YES] response indicates a possible risk factor that must be evaluated by a physician. If any of these
conditions apply to you, then you must obtain approval to dive from a physician before participating in any SSI Dive Experiences or SSI
Dive Programs.
1. Are you currently being treated or under the care of a medical professional for a medical, mental or physical
condition? [NO] [YES]
2. Do you take prescription medication(s) (not including birth control)? [NO] [YES]
Do you currently have or have you been treated within the last two years for any of the following:
3. A heart, circulatory, blood, blood pressure, or bleeding abnormality? [NO] [YES]
4. A stroke, seizure, head injury, loss of consciousness, behavioral, or neurologic condition? [NO] [YES]
5. An ear, sinus, mouth, throat, or lung disorder – including asthma? [NO] [YES]
6. Diabetes, severe allergies, obesity, stomach or intestinal disorders? [NO] [YES]
7. Musculoskeletal, stamina, strength, or mobility disorders that aects your ability to swim? [NO] [YES]
If you answered YES to any of these questions, then you must be evaluated by a physician who must approve you to dive, prior to any in-water
diving activities. You are responsible for obtaining a completed Physician’s Approval to Dive form and provide that completed form to your
instructor before any in-water dive training.
Additionally, if you are under the inuence of alcohol or recreational drugs, unable to swim, prone to panic attacks, unable to exercise good
judgment or you are unable to be responsible for you own wellbeing, then you have a signicant increase to risks of illness, injury and death
while in the water and you should unconditionally refrain from swimming or diving. Failure to complete this form truthfully may result in
serious illness, injury or death.
I explicitly agree to accept full responsibility for failing to disclose any past or current health condition that aects my safety while diving.
Participant’s Signature
Date (DD/MM/YY)
Signature of Parent/Guardian (When Applicable)
Date (DD/MM/YY)
Physician
Physician’s Impression
❏ I nd no medical conditions that I consider incompatible with diving. ❏ I am unable to recommend this individual for diving.
Physician’s Signature or Legal Representative of Medical Practitioner
Physician's Name or Stamp
Date (DD/MM/YY)
Clinic/Hospital
Address
Phone Email
By placing my name here, I agree to be responsible for the content of this page.
First Name Last Name
NOTICE: Electronic Signature Agreement. By typing/placing your name on the signature box, you
are signing this Fit To Dive Screening electronically. You agree your electronic signature is the legal
equivalent of your manual signature.
click to sign
signature
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© SSI International GmbH | TR-PRIVACY_English-Metric | 07272019
By placing my name here, I agree to be responsible for the content of this page.
First Name Last Name
Privacy Policy
This Privacy Policy explains why SSI Training Centers obtain your personal data for the purposes of conducting your training, issuing
certications, administration of your private information and any other necessary specics 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
certications and administration of your personal data stored in the MySSI system at SSI International GmbH, Johann-Hoellfritsch-Straße 6,
90530 Wendelstein, Germany, Email: info@diveSSI.com, 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
privacy@diveSSI.com.
1. SSI Authorized Training Center “Data Controller”
SSI Training Center Name _______________________________________________________________________________________
Street, PO Box _______________________________________________________________________________________
ZIP Code, City _______________________________________________________________________________________
State, Country _______________________________________________________________________________________
2. Personal Data
“Personal data” is any information relating to an individual person (“data subject”). An identiable natural person is one who can be identied,
directly or indirectly, by reference to information such as a name, identication number, location data, or online identication. 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 certication, therefore we need to collect and process the following personal data:
• First and Last Name
• Address, Post Box
• Postcode, City
• State, Country
• Email Address
• Telephone Numbers (optional)
• Date of Birth
• Gender
• Photo
• Language
• SSI Master ID
• Course Type, Course Progress
• Certication Data (Number, Date, Instructor,
Instructor Number, Number of Certication
Dives, Certication Year)
• Training Center Aliation
• MySSI App Geo Locations
• Medical Information
• Insurance Data (when applicable)
• SSI Professional Number (only for
SSI Professionals)
• Quality Assurance Data (for Professionals)
NOTE: The personal data we collect is for the sole purpose of delivering training content, processing, issuing and delivering certications, 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, Certication
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 certication 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 certication 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 prole, training progress, certications, education level and much more.
Upon completion of all academic, pool and open water training, SSI will process your digital certication 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 necessary for the performance of a contract (Article 6 (1) (b) General Data Protection Regulation).
By registering in MySSI, you are consenting to share your personal data: Name (First and Last), Address (Postbox), Postcode (Zip), City, State,
Country, Email Address, Telephone Numbers (optional), Date of Birth, Photo, Language, Gender, SSI Master ID, Course Type, Course Progress
and Certication Information (Name, SSI Training Center, Certifying Instructor, Year You Started Diving, Level of Experience, Number of Dives
and Issue Date), plus your Training Center Aliation. Additionally, you are consenting to share all personal information voluntarily provided
80206, Denver
557 Milwaukee Street
Denver Dives with Ali, LLC d/b/a Denver Divers
Colorado, U.S.A.
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© SSI International GmbH | TR-PRIVACY_English-Metric | 07272019
By placing my name here, I agree to be responsible for the content of this page.
First Name Last Name
by you and stored in MySSI (e.g. – specic diving insurance policies (when applicable), Medical Statement for Student and Professional)
for processing certication through other SSI Service Centers. You may choose to aliate or do business with any SSI Service Center or SSI
Training Center around the world. For a complete list of all Service Centers and Training Centers log on to https://my.divessi.com/ssi or https://
my.divessi.com/divecenter.
By giving your consent, SSI Training Centers may subsequently access your personal data described above in order to identify you, verify
or conrm the status of your training and certications and to oer you continued training and services based on your diving experience.
For more information on the relevant data processing and data sharing accessed in the MySSI system, go to MySSI Privacy Policy https://
my.divessi.com/myssi_privacy.
Legal basis for the described processing is consent (Article 6 (1) (a) General Data Protection Regulation).
4. Special rules for youth under the age of 16
Youth under the age of 16 cannot participate in any SSI training without the explicit consent of their parent or legally appointed guardian.
Personal data for youth under the age of 16 is only used for conducting training and issuing certications as described above.
Youth under the age of 16 who visit www.diveSSI.com cannot register or use the MySSI system without consent from their parent or legal
guardian. SSI strongly recommends that the parent or legal guardian closely monitor their youth’s internet activities until they are of legal age.
5. Transferring your personal data to third parties
In the event of a diving incident or a complaint against an SSI Professional, your SSI Training Center may transfer your personal data to SSI (SSI
International GmbH, Johann-Hoellfritsch-Straße 6, 90530 Wendelstein, Germany) by email to info@diveSSI.com. As required by law, it may
also be necessary to forward this same information to other SSI Service Centers or third parties involved in a case or in the performance of
this agreement, e.g. – insurance companies, public authorities or other companies aliated with SSI. This is only as necessary for fullling the
training requirement, complying with legal obligations and ensuring our legitimate interests.
Your SSI Training Center will also transfer your personal data to SSI while storing and processing your personal data. If necessary, this includes
the Medical Statement for either the student or the SSI Instructor/Professional for the administration and processing of your training and
certications managed by SSI in the MySSI system – my.diveSSI.com.
The purpose of processing and storing your personal data is necessary for the legitimate interests pursued by SSI (Article 6 (1) (f) General Data
Protection Regulation).
We may also transfer your personal data to the following service providers in order to complete your training:
• IT service providers and/or providers of data
hosting services;
• Service providers of software solutions
who also support SSI in providing services
including marketing tools, marketing agencies,
communication service providers and
call centers;
• Third parties that provide service to you, e.g.
- parcel services for the shipment of your
credentials, payment service providers and
banks for processing payment;
• Other necessary third parties, e.g. - auditors,
insurance companies, legal representatives,
etc.;
• Ocials and other public entities as required
by law, e.g. - tax authorities, etc.; and,
• Industry partners within the dive industry
for the purpose of personalized advertising
of diver training, products and services with
the user’s consent. This includes, for example,
advertising for diving insurance, membership
for divers, promotion of local training programs
and events conducted by Training Centers, etc.
The processing is necessary for the purposes of the legitimate interests pursued by us (Article 6 (1) (f) General Data Protection Regulation).
SSI will transfer your personal data to external service providers only when third parties are processing the data on our behalf. We will enter
into a data processing agreement to ensure that both the security of your data and our information is only used in accordance with our
Privacy Policy.
6. Transferring your personal data to third parties outside of the US/EU/EEA
SSI will transfer your personal data to SSI Service Centers or other contractual partners outside the US/EU/EEA for verication of your SSI
training and certications. However, such transfers do not change anything in our obligation to protect your personal data in accordance
with this Privacy Policy. We will only transfer personal data to a third party or international organization if the controller has provided the
appropriate safeguards.
When information is transferred outside the US/EU/EEA and whether this is to an SSI aliate or vendor in a country that is not subject to
an adequacy decision by the EU Commission, data is adequately protected by the EU Commission approved standard contractual clause;
https://ec.europa.eu/info/strategy/justice-and-fundamental-rights/data-protection/data-transfers-outside-eu/model-contracts-transfer-
personal-data-third-countries_en. For more information on appropriate Privacy Shield certication go to: https://www.privacyshield.gov, or
for a vendor’s Processor Binding Corporate Rules, see: https://ec.europa.eu/info/strategy/justice-and-fundamental-rights/data-protection/
data-transfers-outside-eu/binding-corporate-rules_en.
7. Data Security
SSI takes an appreciable amount of technical and organizational security to protect your personal data from unintentional or unauthorized
modication, deletion, loss, theft, viewing, forwarding, reproduction, use, alteration or access. SSI and our sta comply with condentiality
and data privacy regulations. Likewise, all authorized agents who have access to your personal data to fulll their professional duties are also
subject to the same obligations of condentiality and data privacy.
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© SSI International GmbH | TR-PRIVACY_English-Metric | 07272019
By placing my name here, I agree to be responsible for the content of this page.
First Name Last Name
8. Data Retention
SSI will retain your personal data to the extent permitted in the Privacy Policy. After the end of that relationship, SSI will only retain your
records to perform the purposes set out in this agreement. Additionally, SSI and local law may require your SSI Training Center to retain your
training records for an extended period of time. While in other cases, SSI may only need to retain your personal data for as long as it takes
for administration purposes and to protect itself from any legal claims. For more information about SSI data retention policies, go to; https://
my.divessi.com/myssi_privacy.
In the case of a registered user that does not activate the MySSI account and does not get certied within 12 months after registration, the
user data and account will automatically be user disabled from the MySSI system.
For more information about the MySSI data retention policies, go to MySSI Privacy Policy at https://my.divessi.com/myssi_privacy.
9. Your Rights
Your rights regarding SSI processing and storage of your personal data:
• You have the right to access and receive a copy
of your personal data at SSI, Art. 15 General
Data Protection Regulation (GDPR).
• If your personal data is incorrect or no longer
current, you have the right to modify the
information, Art. 16 GDPR.
• You have the right to obtain verication your
personal data has been deleted from MySSI,
(“right to be forgotten”), Art. 17 GDPR.
• You have the right to receive a copy of your
personal data in a commonly used and legible
format. You also have the right to know that we
may transmit your data to another controller
Art. 20 GDPR.
• You have the right to obtain a copy of
any restriction of processing where the
prerequisites have been met, Art. 18 GDPR.
• You have the right to not be the subject of
a decision based solely on an automated
process, including proling, which may result
in legal consequences or any similar aect
concerning you, Art. 22 GDPR.
10. Your right to object
Where your personal data is concerned for the use of direct marketing, you have the right to object to that use.
Additionally, if we process your data even for legitimate reasons, you also have the right to object at any time if grounds develop out of your
specic situation.
So that SSI may process your inquiry regarding the rights listed above and ensure your personal data is not given to any unauthorized third
parties, please email SSI a short description and clear direction regarding your request to object and or modify your personal data stored
at SSI.
You also have the right to le a complaint with the data protection authority. In particular, the data protection authority in the country or state
of your residence or place of work, if you believe that processing your personal data violated applicable data protection laws, Art. 77 GDPR.
Participant’s Signature
Participant’s Name (Print)
Print Name of Parent/Guardian (When Applicable) Signature of Parent/Guardian (When Applicable)
Date (DD/MM/YY)
Date (DD/MM/YY)
NOTICE: Electronic Signature Agreement. By typing/placing your name on the signature box,
you are signing this Privacy Policy electronically. You agree your electronic signature is the legal
equivalent of your manual signature.
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© SSI International GmbH | TR-INTRO-CODE_English-Metric | 10182019
SSI Introductory Scuba Code - Assumption of Risk,
Liability Release & Hold Harmless Agreement
This form is used for SSI Try Scuba and SSI Basic Diver programs. This is a legal contract terminating your rights to le a lawsuit. Read carefully
before signing. Warning – Scuba diving uses life-support equipment and techniques that have inherent risks that may cause injury, illness,
or death.
In consideration of being allowed to participate in an SSI Introductory Scuba Program, I,
(print name of participant) expressly agree to be bound by this Agreement and comply with the Introductory Scuba Code described
below. I understand this Agreement is between me, my family, estate, heirs, and/or anyone who may have a claim on my behalf, and
(print name of training center), including all instructors, facilities, boats, and dive
sites; in addition to Scuba Schools International (“SSI”), and all respective owners, ocers, employees, representatives, volunteers, agents,
contractors, and any others on their behalves, whether specically named or not (herein referred to as “Released Parties”).
I voluntarily assume all risks of injury, illness, and death, caused by scuba diving and all related activities, whether foreseeable or not, including
but not limited to risks associated with; swimming, entering and exiting the water, falling on, being struck by or abandoned by a boat, holding
my breath, pre-existing health conditions, heart failure, overexertion, panic, drowning, pressure-related injuries, decompression illness,
environmental and marine life injuries, unknown causes, equipment malfunctions, improper dive planning, or improper action of other divers
or support personnel (including failure to rescue, recover, resuscitate, or provide emergency assistance). I understand dive activities are
conducted at sites that are remote, in time and distance, from medical care. I understand these risks and voluntarily choose to participate
despite the risks.
I agree to be responsible to comply with the following SSI Introductory Scuba Code during all diving activities:
1. I am responsible for my own safety and well-being during all scuba dives, including but not limited to; equalizing my
air spaces, breathing normally, maintaining proper buoyancy, and remaining with my dive leader throughout the dive.
2. I am responsible for being physically, medically, and mentally t to participate in scuba diving; and I arm all the personal
information I have provided on the Fit to Dive questionnaire is truthful and accurate to the best of my knowledge; and
I will not hold others responsible or liable for any injury, illness, or death caused by my failure to disclose a known
medical condition.
3. I am responsible for monitoring my air supply and ending my dive with at least 500 psi/35 bar.
4. I am responsible for immediately notifying my dive leader if I am not comfortable or I have a problem.
5. I will remain with my dive leader throughout my dive; however, if I become separated and cannot locate my dive leader,
I will ascend to the surface (making sure to exhale during ascent) and establish positive buoyancy by inating my
buoyancy compensator or releasing my weights.
6. I understand dive training does not guarantee my safety and that accidents happen even when proper procedures
are followed.
7. In the event that I do not feel comfortable, capable, or willing to fulll these Responsibilities then I will not dive.
I agree to waive, release, not sue, discharge, save, indemnify, and hold harmless the Released Parties of all claims, demands, causes of action,
lawsuits and damages by me, my estate, family, heirs, or others who may have a claim for my injury, illness, or death as a result of any act or
failure to act, including negligence by the Released Parties, associated with my introductory scuba experience and all related activities. I agree
that it is my responsibility to inform my family and all those who may have legal rights on my behalf that I have entered into this Agreement
and it is my intent that they be bound by the Agreement. I agree that me or my estate shall be fully liable for the cost to Released Parties for
any claim brought on my behalf arising from my participation in scuba diving and all related activities.
I understand SSI licenses SSI Training Centers, SSI Professionals, and their aliates to use various SSI trademarks and to conduct SSI training,
but I agree they are not agents, employees, or franchisees of SSI, its parent, subsidiary, or aliated corporations. I further understand that SSI
Training Centers, SSI Professionals, and their aliates’ businesses are independent, and are neither owned, operated, or controlled by SSI, and
that while SSI establishes standards and materials for SSI training programs, it is not responsible for, nor does it have the right to control, the
operation of the business activities or the day-to-day training programs and/or supervision of divers by SSI Training Centers, SSI Professionals,
their aliated businesses, and/or their associates’ sta. I further understand and agree on behalf of myself, that in the event of injury, illness or
death during dive activities, I shall not hold SSI liable for the actions, inactions or negligence of the SSI Training Center, SSI Professionals, and
other aliated businesses or personnel associates with my dive activities.
I have read this Agreement and the SSI Introductory Scuba Code. I expressly understand my responsibilities and that I am giving up legal rights
by signing this Agreement. I understand this is a legal contract and I am voluntarily signing it without inducement or duress. I understand
this is an unconditional and complete release of all liability to the greatest extent allowed by law. If any portion of this Agreement is found to
be legally unenforceable, that portion shall be severed, and the remainder shall have full legal force. I agree to be bound by this Agreement
without modication of the preprinted text. I am over 18 years of age and legally competent to engage in this Agreement, or I have acquired
the written consent of my parent or guardian by completing the SSI Youth Addendum form.
By placing my name here, I agree to be responsible for the content of this page.
First Name Last Name
Participant’s Signature
Participant’s Name (Print)
Parent/Guardian (Print) Parent/Guardian Signature
Date (DD/MM/YY)
Date (DD/MM/YY)
Denver Dives with Ali, LLC d/b/a Denver Divers
NOTICE: Electronic Signature Agreement. By typing/placing your name on the
signature box, you are signing this Assumption of Risk, Liability Release & Hold Harmless
Agreement electronically. You agree your electronic signature is the legal equivalent of
your manual signature.
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© SSI International GmbH | TR-WAIVER-Youth_English-Metric | 07282019
YOUTH ADDENDUM – INCORPORATED AS AN
ADDENDUM TO THE ASSUMPTION OF RISK, LIABILITY
RELEASE & HOLD HARMLESS AGREEMENT
NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR
MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING
THAT, EVEN IF THE RELEASED PARTIES USE REASONABLE CARE IN PROVIDING THIS
ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY
PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT
IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS
FORM, YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER
FROM THE RELEASED PARTIES IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING
DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS
THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO
SIGN THIS FORM, AND THE RELEASED PARTIES HAVE THE RIGHT TO REFUSE TO LET
YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM AND THE ASSUMPTION
OF RISK, LIABILITY RELEASE AND HOLD HARMLESS AGREEMENT.
THIS YOUTH ADDENDUM TO THE ASSUMPTION OF RISK, LIABILITY RELEASE AND HOLD
HARMLESS AGREEMENT IS VALID FOR ONE YEAR FROM THE DATE OF SIGNATURE.
By placing my name here, I agree to be responsible for the content of this page.
First Name Last Name
Participant’s Signature
Participant’s Name (Print)
Print Name of Parent/Guardian (When Applicable) Signature of Parent/Guardian (When Applicable)
Date (DD/MM/YY)
Date (DD/MM/YY)
NOTICE: Electronic Signature Agreement. By typing/placing your name on the
signature box, you are signing this Youth Addendum electronically. You agree your
electronic signature is the legal equivalent of your manual signature.
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Try Scuba and Basic Diver Participant Registration Form (Rain Retail POS)

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Completed 28 October 2021

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