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Service Member Registration

FIRST NAME

LAST NAME

DATE OF BIRTH

ADDRESS

EMAIL

PHONE

What branch of service did you serve in? *

Army

Navy

Airforce

U.S. Marine

Coast Guard

Space Force

Did you recieve an Honoable Discharge? (Please upload supporting document). *

Yes

No

DD214

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Are you registered in the VA health system? (if so, you will need to upload supporting documents). *

Yes

No

Benefit Summary & Service Verification Letter

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Are you scuba certified? *

Yes

No

If yes, whch organization? (Please upload supporting document). *

PADI

SDI

Other

Copy of Scuba Certification (if applicable)

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Tell us your story. Please submit your biography below.

By checking this box, you confirm that you have answered all question truthfully to the best of your knowledge.

By checking this box, you confirm that you have completely read and agree with the privacy policy and terms & conditions.

YOUR SIGNATURE

THANK YOU FOR REGISTERING!

Deep Blue Dive Therapy Inc is a 501(c)(3) Nonprofit organization registered with the U.S. IRS EIN: 87-3930868

Deep Blue Dive Therapy Inc.

13506 Summerport Village Pkwy, Suite #768

Windermere, FL. 34786

Contact@DeepBlueDiveTherapy.org

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