Course Application

First Name:
Last Name:
Pref Name
Address
City
State:	Select State Select State Massachusetts New York New Jersey Rhode Island Connecticut California NOT LISTED
Zip
Date Of Birth (DOB)
Phone
Student Email:
Personal Email:	** Personal Email Not Required unless you say Yes to email list below.**
Emailing List:	Select Yes/No Yes No  **Select Yes if you want to be kept up  todate on future trips and happenings!**
Instructor:	Select Instructor Select Instructor Jeff Day Jason Shannon Brian Paul
Night:	Select Day of week Monday Tuesday Wednesday Thursday
Semester:	Semester Fall 2023 Spring 2024 Fall 2024
Status:	Select Student TA Guest Instructor Dive Mstr
Height	Select height (Foot) 4' 5' 6' Select height (Inches) 11 10 9 8 7 6 5 4 3 2 1 0
Weight	LBS
T Size:	Select Size - (unisex) S M L XL 2XL 3XL
Student ID
PIN
	No Special Characters!
Emerg Contact Name:
Relationship:
Rel. Phone:
Rel. Email:
"I certify that the above information is correct."
Please enter your name: This will be your Digital Signature!
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