NAME_____________________________________________________________________________________

ADDRESS__________________________CITY_________________________STATE_________ZIP_________

AGE_______DATE OF BIRTH___/___/___SS#____________________________MALE______FEMALE______

HEIGHT_______WEIGHT________T-SHIRT SIZE  MED______LG______XL______XXL_____

PASSPORT #_____________________EXP DATE_________APPLYING FOR PASSPORT AT THIS TIME____

NOTE:  A VALID PASSPORT IS NECESSARY TO TRAVEL TO HONDURAS. 
YOU MAY OBTAIN A PASSPORT FROM ANY CLERK OF COURTS OFFICE.

SCHOOL NAME________________________________________________________GRADE_____________

ADDRESS__________________________CITY_________________________STATE_________ZIP_________

TELEPHONE(      )____-_________NAME OF BIOLOGY TEACHER__________________________________

PARENT/GUARDIAN INFORMATION

NAME_____________________________________________________________________________________

ADDRESS__________________________CITY_________________________STATE_________ZIP_________

DAYTIME PHONE(     )____-_________EVENING PHONE(      )____-_________

FAX #(     )____-________ ATTENTION_____________________E-MAIL_______________________

DEPOSIT ENCLOSED________@$300.00/STUDENT = $___________CHECK #_________MONEY ORDER_________

VISA/MC_______AMEX_______DISC________ACCT. NUMBER_________________________EXP DATE_______

SIGNATURE_________________________________________DATE_________________

ARE YOU INTERESTED IN SELLING T-SHIRTS AS FUND RAISER?________CALL FOR MORE INFORMATION

DIVING HISTORY:

ARE YOU CERTIFIED?__________IF YES, WHAT AGENCY___________LEVEL___________

IF NO, ARE YOU INTERESTED IN A VIDEO HOME STUDY OURSE?____________CALL FOR MORE INFORMATION

NUMBER OF LOGGED DIVES__________DO YOU NEED TO RENT EQUIPMENT?______________

MARINE BIOLOGY RESEARCH CAMP • 210 DENIER DRIVE • LAFAYETTE, LA • 70508 • 1-888-477-MBRC

MEDICAL HISTORY

CHECK THE APPROPRIATE BLANK IF YOU HAVE EVER HAD ANY OF THE FOLLOWING APPLY TO YOU, AND EXPLAIN UNDER REMARKS, INDICATING THE NUMBER.

PRINT OR TYPE REMARKS________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

MEDICAL INSURANCE COMPANY__________________________________________________________________________

PHONE #_____________________________POLICY #________________________________________________

POLICY HOLDER_________________________________________________________________________________________

OTHER INFORMATION____________________________________________________________________________________

______________________________________________________________________________________________________

PLEASE ATTACH A PHOTOGRAPH OF APPLICANT FOR IDENTIFICATION

MEDICAL TREATMENT RELEASE

I DO HEREBY AUTHORIZE GREG HIDALGO OF DIVERS DESTINATION OR HIS REPRESENTATIVE, TO SECURE MEDICAL TREATMENT FOR MY SON/DAUGHTER, _______________________________, IN THE EVENT OF AN EMERGENCY.

MOTHER______________________________

FATHER______________________________

GUARDIAN____________________________

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