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.