Name _________________________________ Telephone ________
Address _________________________________________________
City ____________________________ State ____ Zip ________
Team
Affiliation
__________________
Date
of Birth _________
SCUBA APPLICANTS MUST PROVIDE THE FOLLOWING INFORMATION
Certifying
Agency
and
Number
______________ Years Experience
_____
Registration fee is $55.00 (includes
one
high
quality
t-shirt).
Additional t-shirts may be purchased for $15.00.
Shirt size: Large ____ X-Large _____ XX-Large ____
Please
enclose
this form and
mail with "non refundable" payment to the address at
the top of this page. Mailed registration must be received no
later than May 12, 2010.
Done
this _____
day of
_________________ 2010.
Signed ________________________ Witness _______________________
________________________________________________
Signature of parent or guardian if under 19 years of age.