Step 1 of 4

Select Your Local Dive Warriors Chapter *
First Name *
Middle Name
Last Name *
Home Phone *
Cell Phone *
Home Address *
City *
State *
Zip Code *
Email *
DOB *(mm-dd-yyyy)
Shoe Size
Gender *
In what branch of the service did you serve?
Month and Year of Injury/Illness
My disability is from:
VA disability rating of
If other please explain

Step 2 of 4

SCUBA Certification Information

SCUBA Certification Information
Special Certifications
Number of Dives
Number of Dives Past 12 Months
Approx Date of Last Dive (mm-dd-yyyy)

Dive Accident Insurance (DAN, etc) *

Dive Insurance
Exp Date (mm-dd-yyyy)

• All certified divers must have DAN insurance in order to dive with Dive Warriors.

Are you a certified Diver?
(If you answered "no", skip to documents uploads)
HSA Certification
HAS Cert No
Special Skills

*DIVE PROFESSIONALS: Please provide copies of your Insurance policy

Policy #
I certify by my signature below that the information on this application form is accurate and true.
Print Full name
Date (mm-dd-yyyy)

Step 3 of 4


First Name
Last Name
RELEASE and AGREEMENT. Read carefully and initial each paragraph below. Sign at the bottom to signify your agreement.
CONFIDENTIALITY AGREEMENT: I understand and agree that in performing my services as a volunteer of Dive Warriors, I must hold student medical and other confidential information in strict confidence. Other than to members of the Instruction team for the class where I am volunteering. I agree not to disclose any medical or private/confidential information.
LIABILITY RELEASE: Dive Warriors, a California non-profit corporation, is engaged in SCUBA instruction classes and the sport of SCUBA diving for the handicapped and their dive buddies. SCUBA Diving is an adventure sport with inherent risks which could result in severe injury, paralysis or death. Dive Warriors and all of its officers and directors are hereby release from any liability for injuries incurred while participating as a volunteer in any capacity including he adventure sport of SCUBA Diving. I agree that I and I alone are responsible for my SCUBA Diving decisions including determining the suitability of a dive site and conditions. I undertake the sport of SCUBA Diving of my own free will and have been properly trained by an internationally recognized SCUBA certification agency. I and I alone bear the full responsibility for my dive decisions.
MEDICAL: I certify I am in good health with no known medical conditions that would prevent me from SCUBA Diving. I understand it is my responsibility to maintain my health and not to dive if I am not physically fit to do so.
PHOTO RELEASE: I hereby release and grant to Dive Warriors my consent to the use of my likeness or photograph in the form of pictures in print, electronic media, including internet, their websites, literature, advertising, new releases, DVD/CD, Television and Film presentations.
By my signature below I agree and consent to the above agreements and releases
Print Full name
Date (mm-dd-yyyy)

Step 4 of 4


Acts of misconduct shall subject the Staff Members, Dive members, volunteers and Caregivers to disciplinary action. Allegations of misconduct against any Diver Warriors Staff-member, Dive Member, Volunteer, Caregiver and/or entire organization should be addressed with Dive Warriors main office in Los Angeles. Acts of misconduct may be defined as conduct or behavior that may compromise the integrity of Dive Warriors and are prohibited. Such misconduct includes but is not limited to:

  • Violation of any local, state, or federal law, violation of the Code of Conduct or any other policy, rule, or regulation
  • Consumption of alcohol by any Staff Member, Dive Member, Volunteer, Caregiver or any other affiliate of Dive Warriors at any event, trip, or function that involves scuba diving (This is a zero-tolerance policy and will result in immediate suspension of the member).
  • All members agree to follow staff instructions at all times, especially instructions given to divers underwater. Failure to obey will result in suspension and expulsion.
  • Harassment or sexual harassment
  • Repeatedly missing planned events after confirming your attendance without canceling 48 hours in advance.
  • Sexual assault or misconduct
  • Striking, attempting to strike, or otherwise physically abusing any person during an event.
  • Inciting members to violent or abusive action intentionally, or with careless disregard for one's conduct
  • Using obscene gestures or profane provocative language or action toward any other member of Dive Warriors.
  • Using the Dive Warriors name or logo in any way to raise funds without the organizations express written consent.
  • Committing any act of misconduct not specifically described above shall subject violators to any of the described penalties which the Dive Warriors Board of Directors determines most suitably addresses the conduct involved.

In addition to any assessed penalty, Dive Warriors may take any remedial action believed to be proper to deter any future misconduct. Staff Members, Dive Member and Caregiver concerned about inappropriate activity by another Staff Member, Dive Member, Volunteer or Caregiver should contact Dive Warriors Main Office for assistance.

I, the undersigned have read and agree to the rules above. I furthermore understand that any violation of the above stated rules could result in my membership from Dive Warriors being revoked.

Print Full name
Date (mm-dd-yyyy)


DIVE PROFESSIONALS: Please provide copies of your Insurance policy
Upload File (only a PDF, JPG, JPEG, or PNG)
ALL APPLICANTS: Please provide your VA DIsability Letter:
Upload File (only a PDF, JPG, JPEG, or PNG)
ALL APPLICANTS: Please provide your DD214 form:
Upload File (only a PDF, JPG, JPEG, or PNG)