Scuba Forms Underwater Astronaut Trainer Release And Medical Form printable pdf download

SCIVIS - SCUBA ADVANCED SPACE ACADEMY

Underwater Astronaut Trainer

Dan Oates

190 Armstrong St., Romney, WV 26757

Release & Medical Form

(Part 1 of 2)

Fax: 304-822-4898

Please read each of these pages carefully and provide complete information. Incomplete forms and/or failure to provide the required signatures will prevent trainee from

participating in all activities. We must have an original physician’s signature on the Scuba Health Form & Medical Release before we can consider your participa-

tion in the Underwater Astronaut Training activity. We cannot accept physician assistant, nurse practitioner or stamped signatures. Return completed forms no

later than four weeks prior to camp session start date. Maintain a copy for your records.

Scuba Waiver & Release Agreement

You must be 14 years old at the time of camp to SCUBA dive. No exceptions! Parent/guardian, trainee

and witness must sign this form. Incomplete forms and/or failure to provide the required signatures will prohibit trainee from diving.

Trainee: ___________________________________________________________________________________ Date of Birth: _______ / _______ / _______

LAST NAME

FIRST

MONTH

DAY

YEAR

Account Number: _____________________________________________________ Session Date: _____________________________________________

For and in consideration of permitting me (print name), , ____________________________________________________________________ to participate in

™

skin and scuba diving activities and/or instruction provided by the U.S. Space & Rocket Center

, SPACE CAMP

, ACADEMY

involved in the activity and/or training.

NAUI, other nationally recognized diving agencies, the U.S. Space & Rocket Center, SPACE CAMP, ACADEMY, their employees and agents such activities

and/or training in the city of Huntsville, county of Madison, in the state of Alabama, with scheduled activities to begin on (enter date)

_______________ , 20 ___,

I state and agree as follows:

I hereby voluntarily release, discharge, waive and relinquish any and all claims or cause of action for personal injury, property damage or wrongful death occurring

to me and arising as a result of engaging in skin and scuba diving activities and/or instruction and any activities incidental thereto, wherever and however such injuries

may occur and for whatever period of time said activities or instructions may continue, and I do for myself, my heirs, executors, and administrators and assigns hereby

release, waive, discharge and relinquish any actions to causes of action which may hereafter arise for me or my estate, and I agree that under no circumstances will

I or my heirs, executors, administrators and assigns prosecute, present any claim for personal injury, property damage or wrongful death against any of those identified

above, as a result of the negligence or otherwise, of those parties in

above.

I have been fully advised of the hazards and dangers incidental to engaging in the activity and/or instruction of skin and scuba diving and I hereby assume all such

risks and dangers attendant to those activities, including negligence, if any, of those parties named in

above.

BY SIGNING THIS AGREEMENT, I RELEASE NAUI, AND THE OTHER PARTIES IN

ABOVE, FROM ANY CLAIM OR CAUSE OF ACTION I, OR MY ESTATE,

MAY HAVE FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH ARISING FROM SKIN AND SCUBA DIVING ACTIVITIES AND/OR

INSTRUCTION, WHETHER CAUSED BY THE NEGLIGENCE OF SAID PARTIES OR OTHERWISE. I AGREE TO HOLD NAUI AND THE AFOREMENTIONED

PARTIES HARMLESS FOR ANY INJURY OR DEATH WHICH MAY OCCUR TO ME DURING SKIN AND SCUBA DIVING ACTIVITIES AND/OR INSTRUCTION.

I hereby declare I am of legal age and am competent to sign this waiver and release agreement or that my parent or guardian has signed this document on my behalf

if I am a minor. Missing or improperly placed signatures or any alterations to this form will prohibit me from participating in diving activities.

I HAVE READ THIS AGREEMENT, UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

TRAINEE SIGNATURE

PARENT/GUARDIAN SIGNATURE

(Required if trainee is under 18 years of age)

WITNESS SIGNATURE

PRINT WITNESS NAME

If applicable, phone number where a parent/guardian may be reached during day: (

) ____________________________________

What is the UAT ?

Please initial each section after reading. Parents initials required if trainee is under 18 years of age.

The UAT/Underwater Astronaut Trainer, at the U.S. Space & Rocket Center in Huntsville, Alabama, is a neutral buoyancy simulator like those used by the astronauts

Parent

and design engineers at NASA’s Johnson Space Flight Center and Marshall Space Flight Center. Neutral buoyancy simulators allow astronauts to practice on Earth

Initials

the missions that they will do in space.

Advanced Academy trainees participate in neutral buoyancy/microgravity simulations similar to those used by the astronauts in practicing for space missions. In

Trainee

order to dive safely, there is a one hour classroom orientation on basic SCUBA concepts and safety practices. Trainees also undergo in-water instruction on our 4-

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foot training platform to prepare for neutral buoyancy exercises. Approximate SCUBA time is 1.5 to 2 hours.

There are medical conditions that disqualify a person from participating in SCUBA activities. Insulin-dependent diabetics, epileptics, persons with a history of reactive

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airway disease or asthma, and persons with certain other medical conditions WILL NOT dive.

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This list is not all-inclusive and other conditions may warrant disqualification from diving. All SCUBA forms are reviewed by our medical staff and our instructors who

make the final determination on fitness to dive. Ultimately, the medical staff and staff instructors will decide who does and does not dive.

Trainee

Even if it is well-controlled, IDDM (Insulin-dependent diabetes) disqualifies a diver because the warning symptoms of hypoglycemia may be suppressed, resulting in

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loss of consciousness without warning and because an insulin reaction underwater could very well result in drowning.

Epilepsy disqualifies a diver because underwater, a diver may be exposed to possible triggering stimuli for convulsion. Convulsions underwater often involve breath

holding during the tonic and clonic phases, making pulmonary barotrauma likely, as well as drowning.

Major concerns with reactive airway disease are that the asthmatic diver could develop bronchospasm while diving and is at risk of pulmonary barotrauma, even with

a normal ascent. Underwater, the diver is exposed to many factors which may precipitate bronchial spasm: exercise, cold air, dry air, and anxiety with hyperventila-

tion. Asthmatics can have non-communicating air spaces even on full inspiration, further increasing the likelihood of pulmonary barotrauma. Resolved childhood

asthma can recur later in life and may be precipitated by the cold, dry air in SCUBA cylinders, the increased pressure experienced in going to depth, stress, anxiety,

or the warm water of our facility.

If a trainee is disqualified from diving because of a medical condition or for any other reason, he or she has the option of snorkeling or swimming in the tank while the

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other members of the team dive. Or, the counselor may provide an alternate activity if the trainee does not wish to swim. It is important to remember that the actual

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SCUBA portion of Academy is about 1.5 to 2 hours out of the entire week.

The knowledge and skills taught as a part of the NAUI Entry SCUBA Experience will allow trainees to participate safely in certain activities when under the direct

Trainee

supervision of a NAUI or other nationally recognized agency-certified instructor, assistant instructor, or divemaster. It is not, however, a certification course. Additional

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training is necessary for certification before attempting to dive without leadership supervision.

Further questions can be directed to the Water Training Facilities Office at the U.S. Space and Rocket Center at 256-721-7190 or to the Divers Alert Network

Information Line at 919-684-2948

Parental or physician medical questions or comments should be directed to the Divers Alert Network at 919-684-2948, the Underwater

Astronaut Trainer at 256-721-7190, or e-mail us at: .

Rev. 5/08