Public Safety Diving Phase 1. Application Packet

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1 Public Safety Diving Phase 1 Application Packet Last, First, MI (please print legibly) Date Academy Semester Desired 2508 Blichmann Avenue Grand Junction, CO (970) Rev. 10/1/2013 1

2 Western Colorado Community College Applicant Check-List Review and check-off each item noted below to ensure that you have provided the required document or information as part of your application packet. Complete PSD Application online, if applicable Complete and submit the Western Colorado Community College (WCCC) Application for Admission to: (Current Colorado Mesa University (CMU) or WCCC students please disregard). Western Colorado Community College Admissions 2508 Blichmann Avenue Grand Junction, CO Submit official copy of High School Transcripts or G.E.D scores, and/or College Transcripts from all previous colleges attended to Western Colorado Community College at the address listed above. (Current Colorado Mesa University (CMU) or WCCC students please disregard). Apply for the Colorado Opportunity Fund ( Liability Waiver (signed and dated) Naui Medical Form ERDI Medical Form Past dive logs, if applicable Copy of current valid driver s license Submit copy of current CPR and First Aid certification (if you are not certified, a course will be offered) Physician s Certification of Physical Examination, if needed Program Coordinator Interview Student ID: (700#) 2

Western Colorado Community College Contact Information PLEASE PRINT ALL INFORMATION LEGIBLY Full Name: Date: LAST FIRST MIDDLE Mailing Address: STREET ADDRESS APARTMENT/UNIT # CITY STATE ZIP CODE

3 Western Colorado Community College Contact Information PLEASE PRINT ALL INFORMATION LEGIBLY Full Name: Date: LAST FIRST MIDDLE Mailing Address: STREET ADDRESS APARTMENT/UNIT # CITY STATE ZIP CODE Home Phone: Cell Phone: Work Phone: SSN: Emergency Contact Information Contact Name: Relationship to student: LAST FIRST MIDDLE Best way to contact you during normal hours: Home Cell Work Are you a citizen of the United States? Yes No If no, are you authorized to work in the U.S.? Yes No Do you have any previous scuba training? Yes No If yes, with what agency? Address: (Note: You will receive a Colorado Mesa University account at acceptance to CMU/WCCC.) Date of Birth: Student ID: (700#) 3

4 Questionnaire Is there any information we need to know about your name or your use of another name in order for us to be able to check your work, driving and criminal records? Please specify: Please explain, in your own words, why you seek admission to the Public Safety Diving (PSD) program. How did you first learn about the Public Safety Diving Program? Is there anything in your background or experience that may negatively reflect on your application or ability to complete the public safety dive training program? Please explain. Military Service Branch: From: To: MONTH/YEAR MONTH/YEAR Rank at Discharge: Type of Discharge: If other than honorable, explain: 4

5 Disclaimer and Signature I certify that the previous answers are true and complete. If this application leads to acceptance, I understand that false or misleading information in my application or interview may result in my dismissal from the academy. Signature: Date: 5

6 Western Colorado Community College Liability Waiver The undersigned certifies and agrees to the following terms and conditions: 1. I have no pre-existing condition that would prohibit me from engaging in all training. Initials 2. I understand that Public Safety Dive Training requires physical exertion and physical activity which is undertaken with other persons. My participation in dive training poses a risk of physical injury, illness or other harm to me and I expressly assume all risk and responsibility for any and all injury, illness, and harm of whatever nature, kind or degree. Initials 3. I represent that I am mentally and physically capable of completing 80 plus hours of Public Safety Dive Training which will include a minimum of performing: Swim 250 Yards, non-stop any stroke Tread or Survival bob for 10 minutes Swim 50 feet underwater one breath Swim non-stop with skin diving accessories for 450 yards with mask, snorkel and fins Initials 4. I agree to read and abide by all policies, procedures, instructions, and training methods provided or otherwise made available by WCCC, its instructors and staff, including orientation procedures for new students, WCCC medical treatment policies and procedures, and all other related WCCC, policies and procedures, written and oral. Initials 5. I agree that the health, welfare, and safety of all students, instructors, and staff of WCCC are of paramount importance. I certify that I do not have a communicable or contagious disease or other health condition that poses or could pose a medically recognized, unreasonable or dangerous risk of harm to other students, instructors, or staff at WCCC. Initials 6. I understand that I am responsible for all personal property I choose to bring to WCCC, and I expressly assume all risk of loss of, or damage to such personal property. Initials 7. I also understand that many other aspects of the training at WCCC, such as sub-surface, underwater training, will involve me in situations that could result in harm or injury to me. I further understand that my participation in all of the courses that make up Phase 1 / Underwater Crime Scene Investigations Program is required to receive certification. Accordingly, on behalf of myself, my heirs, assigns, agents, personal representatives, dependants, and all others who may act on my behalf, I forever hold harmless and unconditionally release WCCC, its instructors and its staff, the Board of Trustees of Mesa State College, Mesa State College, and all current and former employees of Mesa State College from any and all liability, claims, demands, actions, and courses of action whatsoever arising from any and all damage, loss, injury or other harm to myself or my property while participating in sub-surface or any other aspect of my training and education while participating in the WCCC program, whether such loss, damage, injury, or harm is caused by my own conduct or that of another person. Initials 8. The terms of this Liability Waiver may be modified only with the written consent of WCCC and are governed by and subject to the laws of the State of Colorado. Initials I certify that I read and understand the English language, and that I have thoroughly read and now understand all the terms and conditions of this Liability Waiver. I further agree that if any section, condition, or term of this Liability Waiver is adjudicated to be unenforceable under applicable law, the remaining sections, conditions, and terms shall not be affected and shall remain enforceable and binding upon me. Signature: Date: Print Name: 6

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13 TM Please print or type MEDICAL EVALUATION AND PHYSICIAN APPROVAL FORM NAME ADDRESS CITY STATE/PROVINCE ZIP HOME PHONE To the Instructor: If any condition listed on the medical history form in the student record folder is checked by the student, you are required to individually interview the student. If, as a result of the interview, you are unsure whether or not the condition is a contraindication to diver training send the student to a physician for a medical exam. In the event that referral to a physician is necessary, provide the student with this NAUI Medical Form and transfer the student s medical history and any notes to the copy to take with them to the physician. To the Physician: This person is an applicant for training in diving with self-contained underwater breathing apparatus (SCUBA). This is an activity which puts unusual stress on the individual in several ways. A list of contraindications is on the reverse of this form for your reference. The student applicant s medical history below was provided during the enrollment process. Behavioral health problems Bronchitis Contact lenses Claustrophobia Tuberculosis Dental plates Agoraphobia Respiratory problems Physical disability Migraine headaches Back Problems Serious injury Epilepsy Back/spinal surgery Over 40 years old Ear or hearing problems Diabetes Hepatitis Trouble equalizing pressure Ulcers HIV positive Sinus trouble Colostomy Regular medication Severe hayfever Hernia Drug allergies Heart trouble Dizziness or fainting Alcohol or drug abuse High blood pressure Recent surgery Rejected from any activity Angina Hospitalized for medical reasons Heart surgery Pregnant Any medical condition not listed: Asthma Motion Sickness Notes : PLEASE RETURN THIS FORM TO THE STUDENT APPLICANT Please note that the medical examination form presents a choice under IMPRESSION. We can only accept unconditional approval as stated for student applicants desiring to begin or continue training. If you conclude that diving is not in the individual s best interest or that their medical condition is likely to present a probable direct threat to others, please discuss your opinion with the person and check disapproval. IMPRESSION: APPROVAL (I find no medical conditions I consider incompatible with diving.) DISAPPROVAL ( This applicant has medical conditions which in my opinion clearly would constitute unacceptable hazards to health and safety in diving.) Date Signature, MD. Physician s Name (print) Address Phone

14 TM CONTRAINDICATIONS TO DIVING This list of relative and absolute contraindications is not all inclusive. Contraindications that are absolute permanently place the diver and his diving partners at increased risk for injury or death. Relative contraindications to scuba may be resolved with time and proper medical intervention or may be intermittent. A bibliography is included to aid in clarifying issues that arise. The Divers Alert Network (DAN) physicians are available for consultation by phone (919) during normal business hours. For diving related emergencies call, DAN at (919) hours, 7 days a week. OTOLARYNGOLOGICAL History of... significant cold injury to pinna TM perforation tympanoplasty mastoidectomy mid-face fracture head and/or neck therapeutic radiation temporomandibular joint dysfunction Recurrent otitis externa Significant obstruction of the external auditory canal Eustachian tube dysfunction Recurrent otitis media or sinusitis Significant conductive or sensorineural hearing impairment Facial nerve paralysis not associated with barotrauma Full prosthodontic devices Unhealed oral surgery sites History of... stapedectomy ossicular chain surgery inner ear surgery round window rupture vestibular decompression sickness Monomeric TM Open TM perforation Tube myringotomy Facial nerve paralysis secondary to barotrauma Inner ear disease other than presbycusis Uncorrected upper airway obstruction Laryngectomy or status post partial laryngectomy Tracheostomy Uncorrected laryngocele NEUROLOGICAL History of... head injury with sequelae other than seizure spinal cord or brain injury without residual neurologic deficit cerebral gas embolism without residual, pulmonary air trapping has been excluded Migraine headaches whose symptoms or severity impair motor or cognitive function Herniated nucleus pulposus Peripheral neuropathy Trigeminal neuralgia Cerebral palsy in the absence of seizure activity History of... seizures other than childhood febrile seizures TIA or CVA spinal cord injury, disease or surgery with residual sequelae Type II (serious and/or central nervous system) decompression sickness with permanent neurologic deficit Intracranial tumor or aneurysm CARDIOVASCULAR The suggested minimum criteria for stress testing is 13 METS. History of... CABG or PCTA for CAD myocardial infarction dysrhythmia requiring medication for suppression Hypertension Valvular regurgitation Asymptomatic mitral valve prolapse Pacemakers-Note: Pacemakers must be depth certified by the manufacturer to at least 130 feet (40 meters) of sea water. Asymmetric sepal hypertrophy and valvular stenosis Congestive heart failure PULMONARY Asthma (reactive airway disease), COPD cystic or cavitating lung diseases all may lead to air trapping. History of... prior asthma or reactive airway disease (RAD)* exercise/cold induced bronchospasm (EIB) solid, cystic or cavitating lesion Pneumothorax secondary to: thoracic surgery *, trauma or pleural penetration*, previous over inflation injury* Restrictive Disease** (*Air Trapping must be excluded) (**Exercise Testing necessary) History of spontaneous pneumothorax Active RAD (asthma), EIB, COPD or history of the same with abnormal PFS or positive challenge Restrictive diseases with exercise impairment GASTROINTESTINAL Peptic ulcer disease Inflammatory bowel disease Malabsorption states Functional bowel disorders Post gastrectomy dumping syndrome Paraesophageal or hiatal hernia High grade gastric outlet obstruction Chronic or recurrent small bowel obstruction Entrocutaneous fistulae that do not drain freely Esophageal diverticula Severe gastroesophageal reflux Achalasia Unrepaired hernias of the abdominal wall potentially containing bowel METABOLIC AND ENDOCRINOLOGI- CAL Hormonal excess or deficiency Obesity Renal insufficiency Diabetics on Insulin therapy or oral anti-hypoglycemia medication PREGNANCY Venous gas emboli formed during decompression may result in fetal malformations. Diving is absolutely contraindicated during any state of pregnancy. HEMATOLOGICAL Sickle cell trait Acute anemia Sickle cell disease Polycythemia Leukemia ORTHOPEDIC Chronic Back Pain Amputation Scoliosis - assess impact on pulmonary function Aseptic osteonecrosis BEHAVIORAL HEALTH History of drug or alcohol abuse previous psychotic episodes Developmental delay History of panic disorder Inappropriate motivation for scuba training Claustrophobia and agoraphobia Active psychosis or while receiving psychotropic medications Drug or alcohol abuse BIBLIOGRAPHY The Physiology and Medicine of Diving, 4th edition, 1993; Diving and Subaquatic Medicine, 3rd edition 1994; Diving Physiology in Plain English, 2nd edition, 1997

Universal Referral Packet

Universal Referral Packet This packet contains everything necessary to complete open water training dives by referral. Referral Student Information: Name: Date of Birth: Emergency Contact: Phone: Referral