Scuba Training Online - Student Registration Form

Student Registration Form

Please completely fill out the following Student Record File to register with the participating facility of your choosing. (Please note items with an (*) are optional) After submitting the form a store staff member will be in contact with you to confirm your registration in the program, collect payment information, and issue a user id and password, along with instructions how to log in to the training site.

If you purchased 'The Complete At Home Study Kit' from a participating outlet, please be sure to keep your receipt or the original packaging as proof of purchase.

To ensure proper submission of your information, please do not use any of the following characters when filling out the form. : , & " ' | ~ ` ( ) + = * / # ^ ;

Participating Facility

Please Note: more stores are being added as the network of participating facilities grow.

Student Information (Confidential)

First Name: Initial: Last Name:

Address:

City: State: Zip:

Phone: Fax(*):

Email:

Birth Date: / / Male Female Married Single

How you heard about this program?(*)
Radio/TV Newspaper Yellow Pages Friend/Relative Internet
Other:

Emergency Contact Information

First Name: Last Name:

Address:

City: State: Zip:

Phone: Alternate Phone(*):

Relationship:

Warning: This program is not intended as a substitute for a scuba course taught by a renewed and insured professional scuba instructor. It is only used in conjunction with existing training materials (text and video, CD-Rom or DVD) to assess a student's knowledge development while participating in a training program offered by the facility. Students should not attempt to use this program without first reading or viewing the preparatory materials. Scuba diving can be dangerous. Students should not attempt to go diving with only the information made available in this program.

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