Spring Lake Dive Authorization Course Registration Form : The Meadows Center for Water and the Environment : Texas State University

Date of DAC *

First Name *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Email *

Age *

Date of Birth *

Gender *

Emergency Contact Name *

Relationship *

Emergency Contact Phone Number *

Certification Agency (NAUI, PADI, etc.) *

Certification Level *

Number of Logged Dives *

Date of Last Logged Dive *

Are You an Instructor? *

Yes

No

If yes, which Dive Shop/Organization do you operate out of?

Are you interested in the PADI Spring Lake Diver Distinctive Specialty Card? *

Yes

No

Are you Texas State Faculty, Staff, or a Student? *

Yes

No

Are you a Veteran? *

Yes

No

Are you currently employed or a Student with another university or State Agency? *

Yes

No

Did you book through a Dive Shop? (You paid a dive shop $30 to reserve your spot) *

Yes

No

If yes, which Dive Shop?