SCUBA Scholarship Application

Please complete the application.  All information is keep confidential and destroyed monthly.

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Please identify and describe yourself: (age will be verified and height/weight is used to help determine gear size.

First Name
Last Name
Middle Initial
Date of Birth
Sex Male Female
Height
Weight
Hair Color
Eye Color
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

Briefly describe why you wish to become a certified diver?

Are there any special considerations you have that you would like to let us know about?


This site was last updated 07/08/09  

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