LARIMER COUNTY DIVE RESCUE TEAM MEMBERSHIP APPLICATION

Applicant's Full Name

Sex

Home Address

Home Phone

Work Phone

Work Name/Address

Marital Status

Spouse’s Name

Address

Home Phone

Work Phone

Work Name/Address

# Dependents

OTHER EMERGENCY CONTACTS

Name

Relationship

Address

Home Phone

Work Phone

EDUCATION HISTORY

High School Graduate or GED

Colleges Attended

Number of Years Completed

Degree Earned

High School Graduate or GED

List Degree(s)

Specialized Skills Other Than Diving

Why do you wish to become a member of the Larimer County Dive Rescue Team?

DIVER HISTORY

Diver Certification?

Certifying Agency:

Certifying Date

Certifying Level

How often do you dive?

Where do you dive?

When was your last dive?

Have you ever been involved in any type of diving accident?

If Yes, please provide an explanation:

Have you ever experienced the following: (circle all that apply)

If so, please give a description of all occurrences:

Are there any medical problems that may prevent you from participating in high stress diving situations?

If YES, please provide an explanation:

I understand that the Larimer County Dive Rescue Team is a volunteer organization offering no monetary compensation to its members. I am aware that team call-outs occur at any time of the day or night and often in adverse weather conditions. By applying for membership, I pledge to fully participate in scheduled training and respond to team missions or risk losing my member status.

I certify that the above information is true and correct to the best of my knowledge.

Please be sure to include a copy of the Medical History form and Statement of Understanding with this application.

LARIMER COUNTY DIVE RESCUE TEAM

Statement of Understanding

This statement is inteded to inform potential members of the Larimer County Dive Rescue Team (and their dependents) of the possible risks, hazards and adverse environments associated with dive rescue activities. It must be understood that this statement is only general in nature and that unforeseen accidents can and do occur. The following is a list of potential risks, hazards and adverse environments that may be encountered when participation in dive rescue activities.

Zero visibility
Hydraulics
Extreme cold water
Low head dams
Contaminated water
Swift water
High altitude diving
Swift water impacts
Under ice entrapment
Swift water entanglement
Underwater entanglement
Drowning
Underwater sharp objects
Out of air
Pressure related injuries
Equipment failure
Severe injury and death
Hypothermia/Heat stroke

You must understand that YOU make the final decisions concerning your own safety. You have the responsibility to inform the team leader(s), instructor(s) or fellow members anytime you encounter a situation that you feel would be too hazardous for you to participate in. At no time will you be forced into an activity that you feel is unsafe or
above your present skill level.

APPLICANT ACCEPTANCE

I have read this statement and understand that dive rescue activities can be hazardous. I fully accept responsibility for my own safety.

SPOUSE'S ACCEPTANCE

(SPOUSE) I have read this statement and understand that dive rescue activities can be hazardous. I fully accept responsibility for my own safety.

Student Medical History Questionnaire

The purpose of this medical questionnaire is to find out if you should be examined by your doctor before participation in public safety dive operations. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a pre-existing condition that may affect your safety while diving. You may be asked by your instructor to seek written approval of a physician prior to participating in diving activities.
Please print legibly.

Name:

Mailing Address

City

State

Zip:

Country:

Home Phone:

Work Phone:

Birth Date:

Name of your family or Primary Care Physician:

Street Address:

City

State

Zip:

Country:

Date of last physical examination:

Name of examiner:

Address:

Phone:

Were you ever required to have physical for diving?

If YES, when?

If YES, why?

Current Prescription Medication (list):

Current Allergies (list):

Blood Type:

Blood Pressure:

Approximate Number of Years Diving:

Approximate Number of Trouble-Free Dives

Emergency Contact:

Name:

Relationship:

Address:

Home Phone:

Work Phone:

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these apply to you, we may request that you consult with a diving physician prior to participating in scuba diving or dive team activities.

Could you be pregnant or attempting to become pregnant?

Do you regularly take prescription or non-prescription medication?

Are you over 40 years of age?

Have you ever had or do you currently have…

Asthma, wheezing with breathing, or wheezing with exercise?

Frequent or severe attacks of hay fever or allergy?

Frequent colds, sinusitis or bronchitis?

Any form of Lung Disease?

Pneumothorax (collapsed lung)?

History of chest surgery?

Claustrophobia or agoraphobia (fear of closed or open spaces)?

Behavioral health problems?

Epilepsy, seizures, convulsions, or taking medications to prevent them?

Recurring migraine headaches or take medications to prevent them?

History of “Black Outs” or fainting(full/partial loss of consciousness)?

Do you suffer from “Motion Sickness” (seasick, carsick, etc..)?

History of diving accidents or decompression sickness?

History of recurrent back problems?

History of back surgery?

History of diabetes?

History of back, arm, or leg problems following surgery, injury, or fracture?

Inability to perform moderate exercise (walk one mile within 10 minutes)?

History of high blood pressure or do you take medicine for high blood pressure?

History of heart attacks?

Angina (heart-related chest pain)?

History of heart or blood vessel surgery?

History of ear or mastoid infections after the age of 10?

History of ear or sinus surgery?

History of ear disease, hearing loss, or problems with balance?

History of problems equalizing ears with airplane or mountain travel?

History of bleeding or other blood disorders?

History of any type of hernia?

History of ulcers or ulcer surgery?

History of colostomy?

History of drug or alcohol abuse?

I hereby certify the above is correct to the best of my knowledge.

Date for acceptance

Physician’s Impression (optional)
Remarks

I find no defects that I consider incompatible with diving.

I am unable to recommend this individual for diving.

Physician Name

Date for Physician Signature

Address

City

State

Zip

Phone

I hereby certify the above is correct to the best of my knowledge

It's Our 50th Anniversary!

LARIMER COUNTY DIVE RESCUE TEAM MEMBERSHIP APPLICATION

OTHER EMERGENCY CONTACTS

EDUCATION HISTORY

DIVER HISTORY

LARIMER COUNTY DIVE RESCUE TEAM

Statement of Understanding

APPLICANT ACCEPTANCE

SPOUSE'S ACCEPTANCE

Student Medical History Questionnaire

Emergency Contact:

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