Application

Name*

First Middle Last

Please include First, Last Name along with a Middle Initial...If you do not have middle name, please indicate with, "NMN"

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please provide a complete mailing address

Email*

Enter Email Confirm Email

Email address is required to submit application

Date of Birth*

Date of birth is required to submit application

Male or Female*

Male
Female

Cell Phone Number*

phone required if cell phone is not available

What branch of the military did you serve?*

Please select the branch of service you served in to submit application

Last Rank Held*

What was your rank when discharged from the Military?

Dates Served*

Please indicate the period(s) of time you served in the Military

Describe Injury or Disability sustain while serving? Please provide as much detail as possible.*

Please be as detailed as you can regarding injuries or disability ratings. Our instructional staff must be aware of injuries to insure no further injuries are sustained or existing injuries are aggravated.

File

Upload VA Rating Letter*

Drop files here or

Upload VA Rating Letter for qualifying veterans

What is your Height?*

The following information will assist us in having dive gear available in the proper sizes.

What is your current Weight?*

What is your T-Shirt Size*

T-Shirt are crew neck men t-shirts

What is your Shoe Size*

Are you currently Scuba Certified?*

Yes
No

Are you currently or have you ever been Scuba Certified?

If answered "YES" Level of Certification and Name of Agency

Most classes are conducted on the weekends. Would you and your buddies schedule allow you to participate in a class during the week?*

Yes
No

Class Availability

Do you have a Dive Buddy you wish to join you in the training program*

Yes
No

Referred By

Additional Comments

Dive Buddies Name

First Middle Last

Please include First, Last Name along with a Middle Initial... If you do not have middle name, please indicate with, "N/A"

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please provide a complete mailing address

Relationship

What is the relationship to the Veteran Applicant

Dive Buddies Email

Enter Email Confirm Email

Dive buddies email

Dive Buddies Cell Phone

Dive buddies phone required if cell phone is not available

Dive Buddies Date of Birth

Dive Buddies Date of Birth required.

Male or Female

Male
Female

Dive buddies Height?

The following information will assist us in having dive gear available in the proper sizes.

Dive Buddies Weight?

Dive buddies T-Shirt Size

T-Shirt are crew neck men t-shirts

Dive buddies Shoe Size?

Is your currently Scuba Certified?

Yes
No

Are you currently or have you ever been Scuba Certified?

If answered "YES" to being SCUBA certified please describe

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