LAST NAME: _______________________ FIRST NAME: _____________________________________________

DATE OF BIRTH: ________________AGE: _______ PARENT’S EMAIL: __________________________________

PARENTS FIRST NAME: ________________________________________________________________________

ADDRESS: ___________________________________________________________________________________

CITY / STATE: _________________________________ ZIP: ___________________________________________

PHONE: WK _______________________HM: __________________________CELL: ________________________

EMERGENCY CONTACT: NAME _____________________________ PHONE: ______________________________

INSURANCE CARRIER: ____________________________________ POLICY#: _____________________________

Please describe any medical problems, medication, allergies or physical limitations you may have:

__________________________________________________________________________________________

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DAYS: ____________________________________ TIMES: _________________________________________

DAYS: ____________________________________ TIMES: _________________________________________

DAYS: ____________________________________ TIMES: _________________________________________

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LESSON FEES - CHECK PAYABLE TO COUGAR DIVING CLUB

COUGAR DIVING CLUB REGISTRATION - $25 PAYABLE TO COUGAR DIVING CLUB (Fee includes Cougar Diving T-Shirt)

AAU Diving Insurance – Please sign up online at our website where there is a link to AAU.

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I, the undersigned, understand that there are inherent dangers involved in the sport of diving, as well as in the use of related training devices such as the trampoline and dry land equipment, both of which are optional. I further understand that participation in this program may expose oneself to certain risks of injury. I freely and voluntarily assume any and all risks of injury, and hereby release the University of Houston, the diving coaches, its regents, officers and employees from any and all claims or liabilities for injuries in any way arising from participation in the Cougar diving club’s program.

Signature of participant: _______________________________________________________________________________

If under 18, signature of parent / guardian: ________________________________________________________________