Permission Slip

I, as parent, and/or authorized guardian of    (a minor) do hereby give my permission of said minor to participate in all authorized trips and excursions.  I further authorize the counselors, Michael Lopatka, Carie Lopatka, Michael Brooks, and Heather Medve, to give, administer and obtain all necessary emergency medical and related services for said minor, and sign boat release forms and immigration forms, and act as temporary guardian. I further understand and agree that I am responsible for payment of all medical fees and services.  

All entry level students (open water) will receive a six month complementary membership with insurance from the Divers Alert Network, contingent upon the return of the proper forms.  All pleasure divers and other dive students are not covered by this complementary membership, however they do have the opportunity to become DAN members and purchase their own insurance. I understand that many insurance policies will not cover diving related emergencies that DAN insurance does.  I understand that should myself or my child require emergency medical treatment including evacuation, decompression services, or any other diving related treatments, that I am responsible for payment of all medical fees and services. 

If a child becomes unruly and normal disciplinary action is not effective that child will be sent home at the parent's expense.  Parents will be notified ahead of time, if the child is to be sent home.  I have read and understand the refund policy.  

Circle one of the below choices:

YES I allow my student's picture to be used on the website, and in other advertisements (i.e. yearbooks, brochures, slide shows, etc.) 

NO I do not allow my student's picture to be used on the website, and in other advertisements (i.e. yearbooks, brochures, slide shows, etc.) 

Signed _____________________________ Date________

Witness _____________________________ Date_______  
Relation ____________________________

Home Phone ______________________________
Work Phone _______________________________

Allergic To: _______________________________
Last Tetanus/DPT: __________________________

Current Medications _________________________ Insurance Company and Policy #: __________________________