PARTICIPANT REGISTRATION

First Name*

Last Name*

Company

Address*

City*

State*

Postal Code*

Country*

Email*

Day Phone*

Evening Phone

Completing this registration form is for eligibility of participation and only needs to be completed one time with our organization. Actual attendance for specific events must be confirmed via securing an Eventbrite ticket for said event. This registration DOES NOT place you on the roster for specific events.

Actual event participation will be monitored through Eventbrite Tickets.

Input Birthdate: Month Day, Year (ex. April 4, 1994)

Please check the boxes that apply to you. If you are a veteran of the military, please email a copy of your DD-214 to info@adaptivescubaprograms.org. This will only be requested once. You do not need to upload for each activity you register to attend.

		Military Personnel (Active Duty)
		Military Veteran (Honorably Separated)
		Physical Disability
		Cognitive Disability
		Other Special Need Group

Please provide details of your disability or other special needs... For example, if you have a physical impairment, are you mobile or confined to a wheelchair? If you selected 'Other Special Needs Group', please describe.

Was the cause of your impairment service related?

		Yes
		No

Are you currently SCUBA Certified? If so, please enter highest level of certification, agency through which you are certified and certification number.

Ex. Open Water, PADI #1234567
or Rescue Open Water, SDI#1234567

Do you have any fears or concerns that may affect your participation in this program?

What do you expect to gain from participating in this program?

How did you hear about this program?

For security purposes, we ask that you enter the security code that is shown in the graphic. Please enter the code exactly as it is shown in the graphic.

Your Code
Enter Code

PARTICIPANT REGISTRATION

Terms and Conditions

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Details of Eligibility

SCUBA Certification ?

Issues/Concerns

Expectations

Referring Source

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