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WHALEFALL NUEVA STUDENT & EMERGENCY INFORMATION


February 23, 2025


First Student's Name

First Name*

Middle Name

Last Name*

Phone*
First Student's Date of Birth*
First Student's Additional Information
Single
Married

Daytime Phone:

Student's Highest SCUBA Cert and Agency

DAN Policy Number and Expiration

Date of Last Dive

Occupation:
First Student's Signature*
Student's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Name:

Home Phone:

Work/Cell Phone:

Address:

Relationship:

Name:

Home Phone:

Work/Cell Phone:

Address:

Relationship:
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Insurance

Insurance Carrier*

Insurance Policy Number*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Additional Information
Single
Married

Daytime Phone:

Student's Highest SCUBA Cert and Agency

DAN Policy Number and Expiration

Date of Last Dive

Occupation:
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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