White Rock Divers Online Registration

Registration

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Welcome to White Rock Divers! Please complete the following registration form. Additionally please fill out our White Rock Divers Policy Online you can find on our website below. https://www.southsurreywhiterockdivers.com/references Email or bring hard copy upon arrival. Will not be able to participate without it.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

Province*

Postal Code*

Home or Primary Phone*

Additional Info

Emergency Contact Info<br/>(Not Contact #1 or #2)*

Contact #1

Contact #1 First Name*

Last Name *

Relationship*

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies/Special Notes

Care Card*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies/Special Notes

Care Card*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies/Special Notes

Care Card*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies/Special Notes

Care Card*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Additional Info

T-Shirt Size

Special Needs (Leave blank if NONE)

Allergies/Special Notes

Care Card*

Please click on the Search button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student