First Name

Last Name

Street Address

City

State

Zip Code

Cell Phone

Do we have permission to send SMS / text messages to this number? Do we have permission to send SMS / text messages to this number? Yes No

Email

Birth Date

Program ProgramUNRESTRICTED SURFACE SUPPLIED DIVER

Highest level of Education Highest level of EducationGEDHigh School DiplomaCollege

Do you need financing? Do you need financing? Yes No Not Selected

Do you need housing? Do you need housing? Yes No Not Selected

Disability Disability Yes No

Disability Description

Are you a veteran? Are you a veteran? Yes No Not selected

Open Water SCUBA certified? Open Water SCUBA certified? Yes No Not selected

Can you swim? Can you swim? Yes No Not selected

Have you attended any other colleges? Have you attended any other colleges? Yes No Not selected