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“Dive for a Cure 2019 Registration”

Please submit this form to Eugene Skin Divers Supply as soon as possible.  You will receive an informational packet when you submit this form. Any dive or game participant is to individually submit a $100 entry fee / donation (which can be part of your collected donations) any time before September 15, 2019 to be eligible for any of the event prizes.  All checks should be made payable to OHSU Foundation with Dive for a Cure in the memo line. 

In addition, our goal is that individual participants collect a minimum of $300 in donations for Dive for a Cure by September 15, 2019.  Although, an individual may participate in the Dive for a Cure event and games, with the minimum $100.00 donation.  If you wish to participate in the underwater poker run, but opt out of diving, please note, your minimum donation is $150.00. Please use the provided donation form to track your pledge money. Submit this form to Eugene Skin Divers Supply. All checks should be made payable to OHSU Foundation with ESDS Dive for a Cure on the memo line.  Oregon Health Sciences University is a non-profit 501(c) (3) corporation.  100% of monies raised will go to the OHSU Knight Cancer Institute in Portland for breast cancer research and education.  Thank you for supporting Dive for a Cure in the quest to raise monies and awareness for Breast Cancer programs in our area.  To be eligible to participate in any games or for any prizes, all pledge dollars must be submitted on or before September 15, 2019.

Registration type:
First Name:
Last Name:
Mailing Address:
City, State & Zip:
T-shirt size:
Name of Emergency Contact / Relationship:
  Emergency Contact Phone number / alt.:
SCUBA Certification Agency:
SCUBA Certification Level:
Participant Waiver:
In consideration of the acceptance of my entry, I, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I have or may have against the organizers of this event, Eugene Skin Divers Supply and Oregon Health Sciences University, its principals, its employees, all sponsors and their representatives and any and all claims of damages, demands, actions whatsoever in any manner, as a result of my participation in the Dive for a Cure event, including travel to and from this event. Any photographs taken before or at the event may be used for promotional purposes.  I attest and verify that I am physically fit and have sufficiently trained for the completion of the event and I have not been advised otherwise by a qualified medical person. Further, I hereby grant full permission to any and all of the foregoing to use my name and likeness in any broadcast, telecast, video or print media of the event without compensation to me.
I have read the previous waiver and agree to assume all risks involved for myself or my heirs.  I also agree to donate a MINIMUM OF $100.00 to the OHSU Knight Cancer Institute to participate in the 2016 Dive for a Cure event.
Parent / Guardian Signature if under 18:



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