Flotilla Use
Date:
Class:
Amount:
Check/Cash
Flotilla 72, St Petersburg, FL - Boating Course Registration Form
Select course
Please Select
Evening BS&S
First Name
*
M.I.
*
If none use NMI
Last Name
*
Today's Date
*
/
Month
/
Day
Year
Date
Address
*
City
*
County
*
Please Select
Pinellas
Hillsborough
Manatee
Pasco
Hernando
Polk
Citrus
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Other (Enter county in remarks.)
State
*
Please Select
AL
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DE
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FL
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MO
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NE
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NH
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OR
PA
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UT
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Other
ZIP
*
Phone Number (Home)
Phone Number (Cell)
E-mail
*
Gender
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Date
Occupation
Note: Minimum age for Class is 14 years. Students under 17 years old must be accompanied by an adult.
Own a Boat?
YES
NO
Type of Boat
Outboard
Inboard
Kayak, canoe, paddle board
Jet Boat
Sail
Other (explain below)
Other:
Length of Largest Boat (feet)
Horsepower
Number Years Boating
How did you learn about our course?
Relative
Newspaper
Friend
Magazine
Dealer
Facebook. Twitter, etc.
Flotilla Web site
USCG Web Site
Other (please explain)
Remarks:
Signature (to be signed in class) __________________________________________________________________
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