SDI Forms-13-Dive Leader Application

Dive Leader Application
Student Info:
Personal and Confidential
Please Print Clearly
Page 1 of 2
Name: _______________________________________________________________ Birth Date: ____/____/____

Last / Family / Surname
Address:
City:
Zip/Postal Code:
Home Phone:
Email:
Occupation:
First / Given
Initial
Day / Month / Year
___________________________________________________________________ M F
__________________________________ State/Province: _________________________________
_______________________ Country: _________________________________________________
____________________________ Daytime Phone: ______________________________________
_________________________________________________________________________________
_____________________________________ Referred by: _________________________________
Emergency Contact:
Name: ____________________________
Address: ____________________________
____________________________
Relationship: ____________________________
Home Phone: ____________________________
Work/Cell Phone: ____________________________
Name: ____________________________
Address: ____________________________
____________________________
Relationship: ____________________________
Home Phone: ____________________________
Work/Cell Phone: ____________________________
Diving History (Please provide a brief explanation of your diving history, attach additional sheets as necessary.):
_____________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Day
Month
Year Certication Number: ____________
Advanced Open Water Agency: ___________ Certication Date: ____/____/____
Diver:
Instructor Name: _________________________________________________________________
Rescue Diver:
Day
Month
Agency: ___________ Certication Date: ____/____/____
Instructor Name: _________________________________________________________________
CPR/First Aid:
Day
Month
Instructor Name: _________________________________________________________________
Divemaster:
Day
Month
Instructor Name: _________________________________________________________________
Assistant Instructor:
Day
Month
Instructor Name: _________________________________________________________________
Day
Month
Open Water Instructor: Agency: ___________ Certication Date: ____/____/____
IT Staff Instructor/ Instructor Trainer Name: ___________________________________________
Instructor Trainer Name: __________________________________________________________
As indicated by my signature below, I am mentally and physically prepared to enroll in this course, in addition, I have provided my
Instructor accurate dive and medical histories.
Student Signature: ______________________________________________________________________________________Date:_____/_____/______
Day
Month
Year
SDI Dive Leader ApplicationPage 2 of 2
DIVEMASTER
Student Name: ____________________________________________________________________________________

Academic Session(s) and Review:
Pool/Confined Water Session(s):
Open Water Session(s):
Date Completed: ____ /____/____
# of Hours: __________
# of Hours: __________
# of Hours: _________
Day
Month
Year
Day
Month
Year
Day
Month
Year
The student above has completed all the Academic, Confined Water and Open Water requirements.
Instructor Name: _ _______________________________________________________________ Instr. # ________________

Instructor Signature: _____________________________________________________________ Date:_____/_____/_ _____
Day
Month
Year
Assisting Instructor Name: _ _____________________________________________________________________________

Student Signature: _ _____________________________________________________________ Date:_____/_____/_ _____
ASSISTANT
INSTRUCTOR
Day
Month
Year
# of Hours: __________
# of Hours: _________

Day
Month
Year
# of Hours: __________
Day
Month
Year
Day
Month
Year
Instructor Name: _ _______________________________________________________________ Instr. # ________________

Instructor Signature: _____________________________________________________________ Date:_____/_____/_ _____
Day
Month
Year
Assisting Instructor Name: _ _____________________________________________________________________________

OPEN WATER
INSTRUCTOR
Day
Month
Year
# of Sessions/Hours: __________
# of Sessions/Hours: __________
# of Sessions/Hours: _________
Day
Month
Year
Day
Month
Year
Day
Month
Year
IT Staff Instructor/Instructor Trainer Name: ___________________________________________ Instr. #________________
IT Staff Instructor/IT Signature: _____________________________________________________ Date:_____/_____/_ _____
Day
Month
Year
Instructor Trainer Name: __________________________________________________________ Instr. #_________________

Instructor Trainer Signature: _______________________________________________________ Date:_____/_____/_ _____
Day
Month
Year

Day
Month
Year
Professional Course Check-Off Sheet

Check off the items listed below as they are completed.
SDI Divemaster
SDI Assistant Instructor
SDI Open Water Instructor
Send Copies to ITI HQ:

Final Exam Answer Sheet
Physician Sign-Off
Dive Leader ApplicationTwo Pages

Physician Sign-Off

Physician Sign-Off
Payment:
Check Included Visa/MC/Disc./Amex:
Credit Card Number: _ ___________________________________________________________ EXP Date: ______/______

Month
Year
Credit Card Holder Signature: _ _________________________________________________________________________

Item # 220300
International Training 2009 v.1109

SDI Forms-13-Dive Leader Application

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Dive Leader Application

Personal and Confidential

Please Print Clearly

Name: _______________________________________________________________ Birth Date: ____/____/____

Day / Month / Year

SDI Dive Leader ApplicationPage 2 of 2

Student Name: ____________________________________________________________________________________

Pool/Confined Water Session(s):

Open Water Session(s):

Date Completed: ____ /____/____

Date Completed: ____ /____/____

Date Completed: ____ /____/____

Instructor Name: _ _______________________________________________________________ Instr. # ________________

Assisting Instructor Name: _ _____________________________________________________________________________

Academic Session(s) and Review:

Pool/Confined Water Session(s):

Open Water Session(s):

Date Completed: ____ /____/____

Date Completed: ____ /____/____

Date Completed: ____ /____/____

Instructor Name: _ _______________________________________________________________ Instr. # ________________

Assisting Instructor Name: _ _____________________________________________________________________________

Academic Session(s) and Review:

Pool/Confined Water Session(s):

Open Water Session(s):

Date Completed: ____ /____/____

Date Completed: ____ /____/____

Date Completed: ____ /____/____

Instructor Trainer Name: __________________________________________________________ Instr. #_________________

Student Signature: _ _____________________________________________________________ Date:_____/_____/_ _____

Professional Course Check-Off Sheet

SDI Assistant Instructor

SDI Open Water Instructor

Send Copies to ITI HQ:

Send Copies to ITI HQ:

Send Copies to ITI HQ:

Check Included Visa/MC/Disc./Amex:

Credit Card Number: _ ___________________________________________________________ EXP Date: ______/______

Credit Card Holder Signature: _ _________________________________________________________________________

International Training 2009 v.1109

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Instructor Name: _ _______________________________________________ Instr. #

Date Completed: //

Date Completed: //

Date Completed: //

Instructor Name: _ _______________________________________________ Instr. #

Date Completed: //

Date Completed: //

Date Completed: //

Instructor Trainer Name: __________________________________________ Instr. #_

Student Signature: _ ___________________________________________________________ Date:_/___/_ _____

Credit Card Number: _ ___________________________________________________ EXP Date: /