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 Sept. 17, 2008.
Done
this _____
day of
_________________ 2008.
Signed ________________________ Witness _______________________
________________________________________________
Signature of parent or guardian if under 19 years of age.