Open Water Adventures Online Registration

Registration

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Please put your preferred class day and time in the comments section below. Once this form is completed, you will receive an email confirming your registration. You will then be contacted to confirm all information. YOU WILL NOT BE CHARGED until enrollment is completed and confirmed.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

Preferred Lesson Days?*

Available 9am-1pm? Yes or No*

Available 4pm-8pm? Yes or No?*

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

Any history of head injury or concussion? (If yes, please explain)*

Any history of Asthma or wheezing? (If yes, please explain)*

Any history of blackouts or fainting? (If yes, please explain)*

Special Needs or disabilities (Yes or No)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Any history of epilepsy, seizures or convulsions? (If yes, please explain)*

Child T-Shirt Size: XS,S, M, L

Adult T-Shirt Size:S,M, L, XL

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

Any history of head injury or concussion? (If yes, please explain)*

Any history of Asthma or wheezing? (If yes, please explain)*

Any history of blackouts or fainting? (If yes, please explain)*

Special Needs or disabilities (Yes or No)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Any history of epilepsy, seizures or convulsions? (If yes, please explain)*

Child T-Shirt Size: XS,S, M, L

Adult T-Shirt Size:S,M, L, XL

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

Any history of head injury or concussion? (If yes, please explain)*

Any history of Asthma or wheezing? (If yes, please explain)*

Any history of blackouts or fainting? (If yes, please explain)*

Special Needs or disabilities (Yes or No)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Any history of epilepsy, seizures or convulsions? (If yes, please explain)*

Child T-Shirt Size: XS,S, M, L

Adult T-Shirt Size:S,M, L, XL

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

Any history of head injury or concussion? (If yes, please explain)*

Any history of Asthma or wheezing? (If yes, please explain)*

Any history of blackouts or fainting? (If yes, please explain)*

Special Needs or disabilities (Yes or No)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Any history of epilepsy, seizures or convulsions? (If yes, please explain)*

Child T-Shirt Size: XS,S, M, L

Adult T-Shirt Size:S,M, L, XL

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

Student Email

Any history of head injury or concussion? (If yes, please explain)*

Any history of Asthma or wheezing? (If yes, please explain)*

Any history of blackouts or fainting? (If yes, please explain)*

Special Needs or disabilities (Yes or No)*

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Any history of epilepsy, seizures or convulsions? (If yes, please explain)*

Child T-Shirt Size: XS,S, M, L

Adult T-Shirt Size:S,M, L, XL

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

(Show-Hide Details)