U.P.

Marine Biological Society

University of the Philippines
Diliman, Quezon City

APPLICATION FORM
AY 2013-2014

Name _____________________________________________________ Nickname _______________________

Present Address ____________________________________________ Tel # ___________________________
Permanent Address _________________________________________ Tel # ___________________________
Birthdate ____________ Sex ____ Cellphone ____________________ Email ___________________________
Person to contact in case of emergency ___________________________________________________________
Address ____________________________________________________ Tel # ___________________________
Name of School ______________________________________________ Course/Year ____________________
Name of Employer/Company ____________________________________ Position ________________________
Address _____________________________________________________ Tel #___________________________
Certified SCUBA Diver?

[ ] Yes

[ ] No

Taken/Taking Skin Diving (PE)?

[ ] Yes

[ ] No

WAIVER
I, ______________________________, hereby absolve the UP Marine Biological Society (UP MBS). from any
liability arising from any untoward incident which may occur during the course of my application with the
organization.

I understand that while all possible measures have been taken to prevent such incidents from

occurring, diving is still a relatively hazardous sport that requires skill and special training.
CERTIFICATION
I certify that I am in good physical condition and have no history of any heart, lung and/or ear ailments that
will prevent me from successfully completing the UP MBS skindiving training, as attested by a qualified doctor. I
further certify that I can swim and am fairly confident with my skills in the openwater (sea).

_______________________________
Signature over Printed Name and Date
___________________________________________________
Signature of Parent/Guardian over Printed Name and Date
(if applicant is below 18 years old)

Other Requirements:
[ ] 2x2 or 1x1 photo
[ ] photocopy of supporting documents (see below)
[ ] application fee - P150 for enrolled UP students (with Valid Form 5)
P250 for non-enrolled UP and other students (with Student ID)
P400.00 for All Others (any valid ID)
[ ] Filled out and signed Application, Waiver and Certification (this form)
[ ] Medical certificate
[ ] SCUBA C-Card or UP Classcard for applicants who are certified SCUBA divers and/or have taken skin diving for PE
Note: All Requirements should be submitted by July 31, 2013 or before Pool Session 1. Those with incomplete requirements will
be dropped from the training program.