Class Sign Up

PADI Rescue Diver

Select a Date:

First Name*:

M.I.:

Last Name*:

Name on certification card (if different):

Date of Birth:

Contact Details

Address*:

City*:

State or Province*:

Zip*:

Primary Phone*:

Type*:

Secondary Phone:

Type:

E-Mail*:

Equipment Sizing

Gender*:

T-shirt size*:

Emergency Contact

Name*:

Relationship*:

Phone*:

Type*:

Alternate Phone:

Type:

Important! Read this!

You're not done! By submitting this form, you commit to making the necessary payments within the next 2 shop business days (the shop is open Tuesday-Saturday). Otherwise, your spot may be given to someone else. Please visit the shop or call us at 734-994-3483 to make your payment.

I understand. I will contact the shop immediately to make my payment.