Expedition Volunteer Program Application

Your Name:
Telephone:
Street:
City:
Nationality:
Date of Birth:
Email:
Dates Requested:
Select One:
Are you a smoker:
Previously Dived w/ MBDE:
Position:
Dive Certification:
Date issued:
Total Dives:
Ocean Dives:
Deeper than 30 metres:
Company and location you last worked at as a DM / Instructor (Position Dive Deck):
Company and location you last worked (Position Domestic):
Managers Name:
Managers Telephone:
Managers Email:
Date employed from:
Date employed to:
Next of Kin Name:
Next of Kin Telephone:
In 100 words or less describe your role and responsibilities with the above employer:

Medical History

Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES.


Do you regularly take prescription or non-prescription medication?:

History of diving accidents or decompression sickness?:

Asthma?:


A high cholesterol level?:

Frequent or severe attacks of hayfever or allergy?:

Frequent colds, sinusitis or bronchitis?:


Any form of lung disease?:

Pneumothorax (collapsed lung)?:

History of chest surgery?:


Epilepsy, seizures, convulsions or take medications to prevent them?:

Recurring migraine headaches or take medications to prevent them?:

History of blackouts or fainting (full/partial loss of consciousness)?:


Do you frequently suffer form motion sickness (seasick, carsick, etc)?:

History of recurrent back problems?:

History of diabetes?:


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

Inability to perform moderate exercise (eg: walk one mile within 12 minutes):

History of high blood pressure or take medicine to control blood pressure?:


History of any heart disease?:

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

History of bleeding or other blood disorders?:


History of any type of hernia?:

History of ulcers or ulcer surgery?:

History of drug or alcohol abuse?:


History of skin disorders, dermatitis, melanomas, skin cancer, etc?: