Name _______________________________________ Telephone ________
Address ______________________________________________________
City ___________________________________ State ____ Zip __________
Team Affiliation _________________________ Date of
Birth ____________
*** Email
Address_________________________________________________
SCUBA APPLICANTS MUST PROVIDE THE FOLLOWING INFORMATION
Certifying Agency and #
__________________________Years Experience _____
Registration is $90.00 (ASA Member) #________ $110.00 (Non-ASA
Members)
Shirt Size________ $20 Extra Shirt Size_________
_______ I will be participating in the flounder jackpot for an
additional $25.00
_______ I will be participating in the snapper jackpot for an
additional $25.00
Done this _____ day of _________________ 2025.
Signed ________________________ Witness _______________________
________________________________________________
Signature of parent or guardian if under 21 years of age.