SCUBA DIVING CHARTER FORM, Jetty Dive Centre

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SCUBA DIVING CHARTER FORM, Jetty Dive Centre – Coffs Harbour, NSW

2023

Read every question carefully. If not filled in properly you will be required to fill it in again.

First Name *

Last Name *

A1/35-39 Bourke Rd *

AlexandriaCity/Suburb *

New South Wales *

New South Wales

Queensland

Australian Capital Territory

Victoria

South Australia

Western Australia

Northern Territory

Tasmania

Other:

2015 *

Australia *

0400553450 *

joe@bkdl.ca *

03/05/1978 *

Please note your full birthday. If you are under the age of 18 years old, signed consent of a parent is required (See below)

YYYY

28/09/2023 *

If you are diving multiple days in a row, select the first day

YYYY

Parent/Guardian Consent

As a Parent or Guardian for the person as listed at the top of this form, note your Full Name as a confirmation for consent of participation in this activity and agreement to LIABILITY RELEASE, WAIVER AND ASSUMPTION OF RISK AGREEMENT

Instructor *

If you have multiple choose the highest qualification.

Open Water Diver

Advanced Open Water Diver

Rescue Diver

Deep Diver

Enriched Air Nitrox

Master Scuba Diver

Divemaster

Instructor

Other:

530082 *

May be listed as "Diver No." If you are SSI yes - this is the big long number.

20/03/2023 *

As listed on your certification Card

YYYY

300 *

100 *

If you have not dived in the last 6 months, please list how long ago your last dive was (eg. 12 months ago)

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