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Student Registration Form
Fill out the form to book your scuba course
Student Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
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June
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September
October
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December
Month
Please select a day
1
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Day
Please select a year
2024
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1924
1923
1922
1921
1920
Year
Place of Birth
*
Gender
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student E-mail
*
example@example.com
Mobile Number
*
-
Area Code
Phone Number
Course you apply to:
Discover Scuba Diving
Open Water Diver
Advanced OWD
Cavern Diver
Nitrox Diver
Deep Diver
Fish Identification
Underwater Naturalist
Other Specialty
Rescue Diver
EFR
Open Water Diver, Advanced, Speciality, Rescue, etc.
From
-
Month
-
Day
Year
Available to start the course
To
-
Month
-
Day
Year
To end before
Weight
KG
Foot size
EU
Height
cm
If you are a diver already and if NOT PADI certified, please fill in the blanks below.
Diver Level
Open Water, Advanced, etc.
Dive Agency
SSI, RAID, PSS or other
Certification Date
When did you get your certification
Student n.
You find it on your dive licence
Number of dives
About
Last Dive
-
Month
-
Day
Year
When was it?
Additional Comments
Signature
Legible signature, thanks!
Submit Application
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