2012 COURSE DATES: AUGUST 4 – 17, 2012 - Sirenian International

Please provide the following information about yourself. Use additional pages if necessary!
* Gender:
* Date of Birth:
* Citizenship:
male female (circle or highligh)
** Passport Country and Number:
** DAN Preferred Membership Number:
*REQUIRED at time of application **REQUIRED at least 60 days prior to fielding
Are you currently enrolled in school? Please give details about your status and program of study. Attach additional
pages if necessary!
Do you want/need credit for this course? How many hours?
If yes, please provide contact information for your academic advisor:
Name:
Department:
University:
Phone:
Email:
Are you SCUBA Certified? YES NO
If yes, provide a copy of your Certification Card and DAN Card.
Tell us about other field courses or field work you have done:
What should we know about your history (allergies, dietary restrictions, psychological conditions, physical or chronic
conditions, etc.) that might affect your ability to participate in this course?
Why did you chose this course? What are you expectations? Do you have any specific background, skills, or talents?
Attach additional pages if necessary!
Tell us about your experiences working with teams, with different cultures, or other situations that demonstrate your
adaptability. Use additional pages if necessary!
Circle or highlight your current swimming ability:
non-swimmer recreational swimmer strong swimmer life-saving certificate
Circle or highlight your comfort level in the ocean:
not at all comfortable in calm seas comfortable in choppy seas
Describe any life saving training you have done, include dates (Red Cross, First Aid, CPR, EMT, etc.)?
What kind of snorkel, SCUBA, and/or boating experience (power, sail, kayak, etc.) do you have?