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Dive Mentor | Enrollment Form
James L. Clark
2021-04-30T00:06:09+00:00
DIVE MENTOR PROGRAM ENROLLMENT FORM
Participant Information
Name
*
First
Last
Do you have a nickname?
Date of Birth
*
mm/dd/yyyy
Social Security Number
*
Mobile Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Participant's Status:
*
High School Student / College Dependent
Adult / Independant
Marital Status:
*
Please note that our dorm-style housing is only available for the candidate. If you have a partner and wish to stay together during your program, you will need to arrange your own housing separately at your own expense.
Single
Married
Civil Partnership
Divorced
Widowed
Choose Your Program
Have you participated in a Dive Mentor program before?
*
Yes
No
What program did you attend before?
Welcome Back! We love it when our alumni return to attend programs again. Which program did you do with us before, and when?
Choose the Program Group you wish to enroll in today:
*
Choose Your Program
High School
College
Professional & Vocational
Recreational / Fun Dives
Adventure Programs
For High School Students
Caribbean Residential Adventure (HS 14 Day)
Caribbean Residential Adventure (HS 21 Day)
Caribbean Voyage Adventure (HS 14 Day)
Caribbean Voyage Adventure (HS 21 Day)
Marine Biology Add-On Module
Other (See Note)
Adventure Programs
For College Students
Caribbean Residential Adventure (College 14 Day)
Caribbean Residential Adventure (College 21 Day)
Caribbean Voyage Adventure (College 14 Day)
Caribbean Voyage Adventure (College 21 Day)
Marine Biology Add-On Module
Other (See Note)
Recreational Scuba Training & Fun Diving
For non-professional (non vocational) training such as Open Water, Advanced, Rescue, Specialties, and fun dives or excursions
Try Dive / Introduction to Diving
Open Water Scuba Course
Advanced Open Water
Speciality Training
Master Diver Program
Fun Diving in Cozumel
Other (See Note)
Vocational Training Programs
For adults 18 years or older (professional training)
Cozumel Dive Master Internship
Cozumel Instructor Training Course
Specialty Instructor Training
Professional Crossover Course
Medical Instructor Courses
Professional Mermaid Training
Other (See Note)
If other, please explain here:
Preferred Location?
*
Preferred number of weeks?
Are you already scuba certified?
*
Yes
No
Social Media
Do you use social media?
Yes
No
Facebook Account
facebook.com/username
Instagram Account
@username
Twitter Account
@username
SnapChat Account
@username
Please upload a passport-type photograph:
Parent Contact Information
Please complete this section if the student is under the age of 18 years old or is currently a dependent.
First Name
Last Name
Relationship to Student
Mother
Father
Other Guardian
Does the student live at the same address as Parent/ Guardian?
*
Yes
No
Parent's Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Best Email
Mobile Phone
Alternative Phone
Emergency Contact
Emergency Contact
*
First
Last
Relationship to Student
*
Mother
Father
Spouse
Other Family Member / Friend
Other Family Member / Friend
Emergency Phone
*
Emergency Email
*
Expectations, Concerns, & Previous Experience
Tell us more:
*
Would you like to answer some questions about your background and expectations? This will allows us to be more informed about how we can ensure you have the best possible experience with us. REQUIRED for all Professional or Vocational Applicants.
Yes
No
Why are you interested in this Program?
What kind of impact do you think it will have on you?
What are your biggest worries or concerns?
Where have you travelled out side of your home country?
What hobbies, interests or personal qualities do you have that you feel will be beneficial to your experience on this Program?
Please describe your experience in the water that is not SCUBA diving related:
Please include any questions or concerns you would like to discuss with a member of staff here:
Scuba Diving Experience
How many years have you been diving?
Location of original scuba certification?
Please list your certifications and the certification agencies (NAUI, PADI, SSI, etc.):
Please upload a scan or photograph of your most recent certification card (front and back):
How many dives have you completed?
Do you have your dives recorded in a log book?
Yes
No
Are you more experienced / comfortable in warm or cold water? Please explain:
Are you a DAN member?
Yes
No
I'd like to become a member
Dan Number:
Please enter your membership number here.
Have you ever had any medical emergencies related to SCUBA diving? Please explain:
Do you ever experience any discomfort when diving? Please explain:
Other Speciality Training Interests:
Your program comes with a number of certifications included in the tuition. As you are already certified, are there any other courses that interest you? (Choose as many as you like)
Boat Speciality
Deep Diving Speciality
Diver Propulsion Vehicle Speciality
Dry Suit Diving Speciality
EAN Nitrox Speciality
Equipment Techniques Speciality
Independent Diver Speciality
Navigation Speciality
Night and Limited Visibility
02 Provider Speciality
Sidemount Diving Speciality
Underwater Photography Speciality
Underwater Videography Speciality
Wreck Diving Speciality
Program Deposit
A non-refundable deposit is required to enroll in all of Dive Mentor programs. We cannot hold or guarantee space until the deposit is received. Each program has its own deposit amount, so please be sure to choose the correct program. You will not be charged the deposit unless you are accepted into a program.
Deposit Amount:
*
Please chose your program deposit amount. Recreational is for Open Water, Advanced, Specialities, etc. Vocation is for Dive Guide, Divemaster, Instructor, etc), Adventure is for Caribbean Residency, Study Abroad, etc.
Recreational Training - $100 USD
Vocational Program - $500 USD
Adventure Program - $1000 USD
Deposit Payment Method
*
Choose Your Payment Method Here
Credit Card (Mastercard or Visa)
PayPal
Bank Transfer
PayPal Address:
Please provide your PayPal address here. An invoice will be generated and sent to you directly.
Name on Credit Card
Credit Card Number
Expiration
CVC
Type of Account
Checking
Savings
Name on Bank Account
Account Number
Routing Number or Swift Code
Help Us Improve Our Reach
Please tell us how you heard about Dive Mentor's programs:
Google (Organic Search)
Google (Ad)
A Friend
Facebook (Organic)
Facebook (Ad)
Instagram (Organic)
Instagram (Ad)
Youtube
Other
Application Processing
Statements of Understanding
*
I understand that if my application is incomplete, I will be denied a place into Dive Mentor's Divemaster Internship Program.
I understand that it will take up to several weeks to process my application.
I understand that space is limited, and I am not guaranteed a spot.
I understand that Dive Mentor requires the execution of a Non Disclosure Agreement (NDA) to process my application, and that this document protects sensitive information and the privacy of both parties. I understand that I will not be offered a spot unless this document is downloaded, printed, signed, and returned to Dive Mentor. This document may be downloaded immediately after this Enrollment Form is submitted.
I understand that I should check my spam/promotions boxes in my email to ensure I do not miss any correspondance and I should consider "white listing" admissions@www.divementor.org to make sure I get emails regarding this application.
Terms of Service
Certification
*
I hereby certify that all of the details I have provided are true and correct to the best of my knowledge. I understand that if any of my statements provided herein are later to be found false, that I may be removed from the program without being refunded my deposit or fees. I further certify that I have read and agree to the Terms of Service.
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