Private Class Request Form
Please fill out the form below. You can expect a call from our shop within 48 hours. *We reserve the right to deny any private request that doesn’t allow enough time to complete the class to meet basic requirements.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Is the main contact also a student?
Yes
No
If yes
Date of Birth
*
-
Month
-
Day
Year
Date
Class Information
What class are you looking to take?
*
Please Select
Private Open Water Diver
Private Try Scuba
Private Refresher
Private Advanced Adventurer
Private Specialty
If you choose Private Specialty above, please let us know which one you are wanting to take.
How many total students will there be
*
Please Select
1
2
3
4
5
6
7
8
Are any students junior divers? (Under 15 years old)
*
Yes
No
Please list all students below
Please list all students below
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Please list any preferences of booking. (Weekends, weekdays and times)
*
When do you need this class completed by?
*
Thank you for completing this form
We will contact you soon! Any questions? Call (512) 451-3425
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