UTD Student Registration Form
Class Title *
UTD Instructor *
If you purchased an authorization code for a class from a shop or facility, please enter the code here.
Online Class
Organizer/refer's Name
Students First Name *
Students Middle Initials
Students Last Name *
Students Street Address *
City *
State/Province *
Zip/Postal Code *
Country *
Students E-Mail *
Mobile Phone Number *
Emergency Contact*
Emergency Phone*
Emergency Email*
Students Occupation
Students Educational Level
Sex *   
Height*
Weight*
Emergency Training*  
Medical Insurance*  
DCS Insurance*  
How's you hear about the class?
Why do you want to take a UTD Class
Are you a certified diver?  
List Your Certifications Levels,
Total Dives
Cave Dives
Wreck Dives
Ice Dives
Double Tank Dives
With Ntrox
With Trimix
With Deco
With Scooter (D.P.V.)
Longest Dive
Longest Deco
Are you able to Swim 300 yards (275 m) in 14 mins? *  
Are you able to swim 50 yards (15 m) on a breath hold? *  
Tell Us a little more about your diving Background
Any Special Requests
Date of Birth * (mm/dd/year)    
Image Verification
captcha Please enter the text from the image