Dive Therapy Program
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District Of Columbia
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
place you on the roster for specific events.
Actual event participation will be monitored through Eventbrite Tickets.
Input Birthdate: Month Day, Year (ex. April 4, 1994)
Select Shirt Size
Select Shoe Size
4 to 6
7 to 8
9 to 11
11 to 13
Please check the boxes that apply to you.
Military Personnel (Active Duty)
Military Veteran (Honorably Separated)
Other Special Need Group
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 ?
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
Do you have any fears or concerns that may affect your participation in this program?
What do you expect to gain from participating in this program?
How did you hear about this program?
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