Application and

Contract for Services

_________________________________________________________
NAME
First M.
(nickname)
LAST

__________
SEX M/F

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ADDRESS Numbers Street name
City
State
ZIP
USA

_________________ ________________
PHONES
Home
Cell

____________________
Alternate

___________
AGE Years

___________________________________________________ _________________
E-MAIL
BIRTHDATE
DD / MONTH / YEAR
PREREQUISITES for PADI Open Water Diver certification include swim ability, over
age 10 (Junior), good health, acceptance, and legal releases of all involved.
I affirm I am the person identified above and am competent to swim, scuba, and travel
to meet the needs of this course. Certification is to performance requirements of the
Professional Association of Diving Instructors (PADI). All accounts must be prepaid
upon booking of course time, gear purchase, or rentals. Referrals, refunds, travel
expenses, air fills,, food and lodging, or site fees are not included.
Revised for 2014, PADI Open Water Diver course fee is $399 per person. Prices vary.
SCHEDULE ___________________________________________________________
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______________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
______________________________________________________________________

Student Signature _____________________________________ Date ___________

Parental approval (if under 21) ____________________________ Date ___________

Checklist for
Open Water Diver||

1. Application
Check I-9 ID______________________________________
2. Schedule
____________________________________ ___________
3. Payment
$____________ payments______________ Due _______
4. Photo
1 x 2 , head and shoulders, no dark glasses, or hats
5. Medical Statement Dennis Burt,
Down2Dive.com
Ft. Worth
Texas
6. Divers Medical Questionnaire 34 YES or NO answers on your Medical History
7. Dr.s Release.
Required before participating if any answer is YES
.
8. Standard Safe Diving Practices Statement of Understanding Dos and donts.
9. Liability Release and Assumption of Risk Agreement ___and Intl Liability 10334
10. Youth Diving
Responsibility and Risk Acknowledgement of Junior divers
11. Knowledge Reviews 1-5
12. Quizzes 1-4
________ ________ ________ ________
13. Final Exam 5
Scores
...........................
________
14. Watermanship
200 yard swim (or 300 yard snorkel) and 10 minute tread
15. Pool Skills 1-5
___/_____ ___/____ ____/____ ___/____ ___/____
16. OW Dives 1-4
___/_____ ___/____ ____/____ ___/____ Dates
17. Referral or
Certification
I understand the training requirements for this course and have successfully completed
all certification requirements. I am adequately prepared to dive in areas and under
conditions similar to those in which I was trained. I realize that additional training is
recommended for participation in specialty diving activities, in other geographical areas
and after periods of inactivity that exceed six months. I agree to abide by PADIs
Standard Safe Diving Practices.
Student Signature_______________________________ Date ___/__________/2014,
DD MONTH YEAR
CONGRATULATIONS
YOU ARE NOW A PADI CERTIIFIED DIVER

Satisfaction survey
On a scale of 1-10 (ten being Best), Id rate my class Instruction ____, speed of
progress ____, ease of comprehension ____, value ____, but it needs more/less
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