Registration FormPlease fill out this form so we can add you to our Liability Insurance Policy for instruction related activities. Name * As shown on your ID First Name Last Name Date of Birth * Date of Birth MM DD YYYY Mailing Address * Street Address City, State, Zip Code Email * This is where we will send you course updates and your certification (if applicable) Phone * Mobile/Text phone number (###) ### #### Line Emergency Contact Name * Your Emergency Contact Person First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Email * Thank you!
