139 Delaware Avenue, Glen Burnie, MD 21061

Telephone: (410) 761-4520

scubahut.com

 

 

Name:________________________________________________Age:_______Sex: __________

Address:_______________________________________________ Phone(H):(___)___________      

         City :_____________________ State: _____  Zip Code:________ Phone(W):(___)___________

Occupation: ____________________________________________Birth date: _______________

Driver's License ________________________________________Email________________________

 

Education:                                                           Graduated           Current Year     Major

                     High School                                  __________            ___________    _______

                     College                                        ___________           ___________    _______

    Graduate/Vocational Work                         __________             ___________     ________

 

Swimming Ability: Poor ______Fair _____Average _____  Good_____ Excellent _____ American Red Cross Swimming ______Life Saving   ______ WSI ________ Other__________

Hobbies: _______________________________________________________________________

Special Interest  _________________________________________________________________

Reason for wanting to take SCUBA:  _______________________________________________________________________________

How did you hear about our program (i.e. radio, TV, newspaper, friend, One Book, Yellow  pages)? 

_______________________________________________________________________________        

 

The cost of the class room and pool sessions is $245.00                                                                      I have included a deposit of $125.00 with this application.

 

The course fee includes a $25.00 non-refundable registration fee.

 A $15.00 a day certification fee is required when certification is done locally.

 

Signed _____________________________________________Date__________

 

 

AFTER THE SECOND CLASS, ALL FEES ARE FULLY EARNED

 

Note: Students under 18 - we welcome your enrollment, however, it is necessary that your parent, or  guardian’s sign below.

 

Parent/Guardian _____________________________________ Date __________