Scuba Diving Participant Registration Form

Personal Information
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(Street, City, State, Zip)
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Are you ambulatory?
Can you walk up and down steps w/ rails in/out of the water?
Do you use a wheelchair?
How do you transfer in/out of your wheelchair?




Do you have sensory deficits?
Has your respiratory system been affected?
Do you have muscle control in your hands?
Do you have muscle control of your mouth or lips?
Do you have a colostomy?
Do you have shunts?
Do you have any cognitive deficits or learning disabilities?

How well do you swim?



Do you have previous SCUBA diving or snorkeling experience?