Student Medical Form

Student Medical History Information Form for all UTD Classes

Medical History Statement: I understand that skin and scuba diving are strenuous activities involving significant pressure changes and that normal, heathly heart, lungs, ear and sinus, are essential prerequisites for my safety and well-being. I hereby confirm that to the best of my knowledge my circulatory and respiratory systems and body air spaces are healthy and normal and that I have no severe emotional or neurological problems or communicable diseases. I understand that I need to seek unconditional approval for diving from a licensed physician if I am uncertain as to my physical fitness for rigors of diving.

Click Y (Yes) or N (No) next to all of the following, and explain under remarks, any Y (yes) answers.

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By electronically submitting this form I agree that all contents are true and that I am bound by it as if I had signed it in person.

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

PLEASE SIGN IN FRONT OF YOUR UTD INSTRUCTOR

Signature of Participant: _________________________________________________________

Printed Name: ______________________________________________________

Date: ___________________

I am a minor and my parent or guardian has signed below.

Signature of parent or guardian if Participant is a Minor, and by their signature they, on my behalf release all claims that they and i have.: _________________________________________________________

Printed Name: ______________________________________________________

Date: ___________________