Amber Waves Diving and Swim Online Registration

Registration

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Welcome to Amber Waves Diving and Swim! Please complete the following registration form.

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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*

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*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Account Information

e-Payment Schedule*

Registration

Referral Information

Family Information

Where do you live?

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Student #2 (Show-Hide Details)

Student #3 (Show-Hide Details)

Student #4 (Show-Hide Details)

Student #5 (Show-Hide Details)

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Required Policies

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