STUDENT REGISTRATION STUDENT REGISTRATION STUDENT REGISTRATION Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Birthdate * MM DD YYYY Todays Date * MM DD YYYY Do You Have Any Health Issues That Might Prevent You From Diving Past Or Present? * Yes No If Yes What Is The Health Issue? Have you ever done a discover scuba or resort course? * Yes No Certification Level * Not Certified Yet Open Water Advanced Open Water Nitrox Rescue Diver Dive Master Instructor Certification Agency * Only If you are a certified diver NOT CERTIFIED YET PADI NAUI SSI SDI BSAC Certification Number * Number on your sea card! When Was Your Last Dive? Only Answer If Your A Certified Diver. MM DD YYYY Do you have your own scuba gear? * Scuba Gear Means BCD and Regulator, Yes No What Size BCD do you wear? * Small Medium Large Extra Large XX Large Do you own a dive computer? * Yes No How Did You Hear About 365 SCUBA? Google Groupon Facebook Instagram Friend Sticker Hell I Don't Know I Groupon or Coupon code? Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### ####
