SCUBA DIVING CHARTER FORM, Jetty Dive Centre – Coffs Harbour, NSW
Full Name *
First name and Surname
Address *
Street Address Including City/Suburb
State/Territory *
Postcode *
Mobile Number *
Email Address *
Birthday *
Please note your full birthday. If you are under the age of 18 years old, signed consent of a parent is required (See below)
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Parent/Guardian Consent
As a Parent or Guardian for the person as listed at the top of this form, note your Full Name as a confirmation for consent of participation in this activity and agreement to LIABILITY RELEASE, WAIVER AND ASSUMPTION OF RISK AGREEMENT
Diver Qualification *
Your Qualification level eg. PADI Open Water Diver, SSI Advanced Open Water Diver, RAID
Certification Card Number *
May be listed as "Diver No." If you are SSI yes - this is the big long number.
Certification Date/Date Issued *
As listed on your certification Card
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Total Dives *
Number of Dives in Last 6 Months *
If you have not dived in the last 6 months, please list how long ago your last dive was (eg. 12 months ago)
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