Scuba Registration Form

Youth Summer Scuba Program Registration Form
Participant's Information

Personal & Health & Contact
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Age (at time of program)
T-shirt Size:
Medical Information
Blood Type
Health Conditions: Any relevant medical conditions
Allergies: Food, medication, environmental, etc
Medications: List of current medications
Dietary Restrictions
Medical Insurance:
Provider Name:
Policy Number:
Scuba Diving Experience
Are you a strong swimmer?
Previous Experience
If yes, please describe (number of dives, location, etc)
Lodging & Sleep Arrangement
Do you have a preferred roommate
If yes, please list their name
Do you have any sleep-related concerns (light sleeper, night terrors, snoring?)
Do you require any special accommodations for sleep (white noise machine, night light, etc)
Do you have any allergies to bedding materials (down feathers, certain fabrics, etc)
Do you have any bedtime routines the staff should be aware of?
Do you have any concerns about staying away from home overnight?
Parent / Guardian Information

(All correspondence and and invoices will be sent to this person)
Name

First NameLast Name
Email
example@example.com
Cell Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts and Authorized Pick Up Persons
Program Information

Program & Payment
Sessions: $3,500 per session or $5,900 for two sessions
Total Cost
Cancellations made before 04/01/25, receive a full refund minus a $50 processing fee.
Cancellations after 04/01/25 are non-refundable, except in cases of medical emergencies (documentation required).
Waivers &Terms
Date

MonthDayYear
Date
Signature
Payment & Impact

Your investment in this experience goes beyond adventure—100% of the proceeds will fund Pa'Ti Mar’s coral nursery project, restoring the reefs that protect Puerto Rico’s coastline. We will send a payment link to your email after this, which must be submitted within 24 hours to secure your child's spot.
Should be Empty:

Youth Summer Scuba Program Registration Form

Participant's Information

Medical Information

Medical Insurance:

Scuba Diving Experience

Lodging & Sleep Arrangement

Parent / Guardian Information

Program Information

Waivers &Terms

Payment & Impact