Participant Information and Questionnaire
Name
Address
City
State
Zip Code
Cell Phone
Email
Date of Birth
Emergency Contact (someone not participating in the class with you)
Emergency Contact Number
Military Branch
Army
Navy
Air Force
Marines
Coast Guard
National Guard
Space Force
Please upload a copy of your DD214 or VA Card
VA Disability Rating
Please select...
None
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Would you like assistance in establishing VA benefits?
Yes
No
Who would you like to learn how to dive with? (Check all that apply)
Spouse
Companion
Children
Friend
Above Persons Name(s) and Date of Birth
Contact Number
What is your availability for training?
Days
Evenings
Weekends
Weekends Only
Other
If availability above is other, what is your availability?
Would you like child care? (Ages 10 and up are welcome to participate)
Yes
No
Do you have any specific concerns or medical issues that you feel might be a barrier to learning how to scuba dive?
Our goal is to assist our fellow veterans in learning new skills that reinforce medical and mental health treatments, develop and foster existing family relations and create a life-long hobby. This is a get-give program. Our hope is that once you learn (get) a new skill, you will be inspired to help (give) other veterans and the local community, and have fun along the way!
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