ECU Scientific Diving Application

NO FIELDS CAN BE LEFT BLANK.
PLEASE ENTER "N/A" IN ANY FIELDS YOU WISH TO LEAVE BLANK.
ACCURATE EMAIL ADDRESS IS REQUIRED.


Your First Name Your Last Name
Name You Like To Be Called
Mailing Address Line 1
Mailing Address Line 2
City     State
Country Postal Code
Home Phone Number
Cell Phone Number or N/A
Email
Date Of Birth "mm/dd/yyyy"    Sex   
Medical Insurance Carrier
Medical Insurance Number
Is This Short Term Insurance? Yes No
Do Have Divers Alert Network (DAN) Insurance? Yes No

ECU Affiliation:
Classification:

Emergency Contact Information:
Name Home Phone Number
Work Phone Number Relationship
Address

SCUBA And Training History:
Date of Your First Scuba Certification "MM/DD/YYYY"    Agency

Please Indicate Completion Of Any Of The Following Courses:
NAUI/PADI Advanced Or Equivalent Yes No
NAUI Master Diver / PADI Advanced Plus Or Equivalent Yes No
Diver Rescue Yes No
Assistant Instructor Yes No
Divemaster Yes No
Instructor Yes No

First Aid Yes No  
CPR Yes No  
Oxygen Administration Yes No  

Please Enter A Password To Allow You Access To Modify Your Record.