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 is $100.00
to enter
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 the safety meeting.
Done this _____ day of
_________________ 2019.
Signed ________________________ Witness _______________________
________________________________________________
Signature of parent or guardian if under 19 years of age.