SCUBA Registration
Name
Please use your full legal name as you would like it listed on your certification card.
Your answer
Email address
Your answer
City
Your answer
Zip Code
Your answer
Phone Number
Please list your cell phone number if possible, or the number best to reach you.
Your answer
Date of Birth
MM
/
DD
/
YYYY
Street Address
Your answer
Is it okay to send you a text message?
Some people don't have text plans or prefer not to receive texts. We respect that, but please indicate if it is an issue.
Required
When would you like to begin?
Visit http://scubawithgabrielle.com/schedule.html for schedule or reply here with specific dates you'd like to begin.
Your answer
Would you like your photo on your certification card(s?)
Required
If you have any special needs or medical conditions, please list details here.
Your answer
Class(es) for which You'd Like to Register
Required
***The following questions are only for already certified SCUBA divers. If you would like to work on advanced certifications, please complete the following. Date of open water certification:
MM
/
DD
/
YYYY
Certifying agency
Total number of logged dives
Your answer
Instructor name
Name or names of instructors with whom you earned your certification(s)
Your answer
Certification #
Please enter your certification card # here.
Your answer
Certification Location(s)
Please list the city and organization where you earned your certification(s).
Your answer
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