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Registration for 

February 15-16, 2020

Dutch Springs Instructor Weekend 

Please fill out the below information to register for the weekend.

 

Don't Forget...

Thursday 2/13/20 @ 9pm
Deadline for completing/changing your group roster
Deadline for purchasing Admission Tickets 

Friday 2/14/20 between 12 noon and 5pm
All online admission for the weekend will be issued

 

Questions? Contact Andrea at andreas@dutchsprings.com

Opening Weekend: April 18-19, 2020

 

 

First Instructor's Name

First Name*

Last Name*
First Instructor's Date of Birth*
I certify that I am 18 years of age or older
First Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
First Instructor's Signature*
Second Instructor's Name

First Name*

Last Name*
Second Instructor's Date of Birth*
Second Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Third Instructor's Name

First Name*

Last Name*
Third Instructor's Date of Birth*
Third Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Fourth Instructor's Name

First Name*

Last Name*
Fourth Instructor's Date of Birth*
Fourth Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Fifth Instructor's Name

First Name*

Last Name*
Fifth Instructor's Date of Birth*
Fifth Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Sixth Instructor's Name

First Name*

Last Name*
Sixth Instructor's Date of Birth*
Sixth Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Seventh Instructor's Name

First Name*

Last Name*
Seventh Instructor's Date of Birth*
Seventh Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Eighth Instructor's Name

First Name*

Last Name*
Eighth Instructor's Date of Birth*
Eighth Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Ninth Instructor's Name

First Name*

Last Name*
Ninth Instructor's Date of Birth*
Ninth Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Tenth Instructor's Name

First Name*

Last Name*
Tenth Instructor's Date of Birth*
Tenth Instructor's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Instructor Number *

Cell Phone Number *

Name of Dive Shop (not affiliated? type- independent) *

Dive Shop Phone Number

Type of class/specialty you are teaching *
What days will you be attending? (select all that applies) *
Saturday 2/15
Sunday 2/16

Number of People Attending (including all instructors) *
We require the names (roster) of all people attending in your group to be submitted by 2/13. Tickets purchased online will not be issued prior to verifying an online waiver on file and a name on a roster. *
The complete roster of divers are listed below.
An incomplete roster of divers are listed below. I will submit my finalized list via the online roster link by 2/13.
I will submit the complete roster via the online roster link by 2/13, after I will finalize my list.

Name of Attendee #1 (please indicate if this person is an instructor)

Name of Attendee #2 (please indicate if this person is an instructor)

Name of Attendee #3 (please indicate if this person is an instructor)

Name of Attendee #4 (please indicate if this person is an instructor)

Name of Attendee #5 (please indicate if this person is an instructor)

Name of Attendee #6 (please indicate if this person is an instructor)

Name of Attendee #7 (please indicate if this person is an instructor)

Name of Attendee #8 (please indicate if this person is an instructor)

Name of Attendee #9 (please indicate if this person is an instructor)

Name of Attendee #10 (please indicate if this person is an instructor)

Name of Attendee #11 (please indicate if this person is an instructor)

Name of Attendee #12 (please indicate if this person is an instructor)

Name of Attendee #13 (please indicate if this person is an instructor)

Name of Attendee #14 (please indicate if this person is an instructor)

Name of Attendee #15 (please indicate if this person is an instructor)
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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