Durland Scout Center
310 Stuyvesant Avenue
Rye, NY 10580
______________________________________________________
SCUBA COURSE REGISTRATION
(please print)
NAME_____________________________AGE_______DATE OR BIRTH___________
ADDRESS______________________________________________________________
CITY______________________________STATE____________ZIP_______________
EMAIL______________________________
FEE ENCLOSED $___________
(make check payable to Durland Scout Center BSA)
__________________________________ | __________________ | |
(Signature Of Student) | (Date) |
__________________________________ | __________________ | |
(Signature Of Parent / Guardian) | (Date) |
IF APPLICABLE
BSA UNIT#________LOCATION___________________________