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PARTICIPANT REGISTRATION
PARTICIPANT REGISTRATION

PARTICIPANT REGISTRATION

First Name*

Last Name*

Company

Address*


City*

State*
Postal Code*

Country*
Email*

Day Phone*

Evening Phone

Terms and Conditions

Terms and Conditions

Completing this registration form is for eligibility of participation and only needs to be completed one time with our organization. Actual attendance for specific events must be confirmed via securing an Eventbrite ticket for said event. This registration DOES NOT place you on the roster for specific events.
Birthdate

Birthdate

Input Birthdate:  Month Day, Year (ex. April 4, 1994)

Select Shirt Size

Select Shirt Size

Select Shoe Size

Select Shoe Size

Please check the boxes that apply to you.
Details of Eligibility

Details of Eligibility

Please provide details of your disability or other special needs...  For example, if you have a physical impairment, are you mobile or confined to a wheelchair?  If you selected 'Other Special Needs Group', please describe.

Was the cause of your impairment service related?
SCUBA Certification ?

SCUBA Certification ?

Are you currently SCUBA Certified? If so, please enter highest level of certification, agency through which you are certified and certification number.

Ex. Open Water, PADI #1234567
or Rescue Open Water, SDI#1234567

Issues/Concerns

Issues/Concerns

Do you have any fears or concerns that may affect your participation in this program?

Expectations

Expectations

What do you expect to gain from participating in this program?

Referring Source

Referring Source

How did you hear about this program?

Verifier

Verifier

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.
Your Code
Enter Code
Search by Keyword

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