Course Registration Form

INSTRUCTIONS

1. You may either fill out the form below on-line and have it submitted electronically or click here to download the forms that you can print out and mail in with your payment.

2. Download, printout and return the Medical form, and Skills Self-Assessment form, along with payment to POWERBOAT SAFETY & OPERATING SCHOOL, 105 15th Ave. SE, St. Petersburg, FL 33701.

Thank you for your interest and if you need assistance with filling out the forms, please give us a call at:
(727) 403-0520 or Toll Free (888) 830-1421
Medical Form Skills Self Assesment Form Mail-in Registration Form

Medical Form

Skills Self Assessment Form

Mail-in Registration Form


Note: Forms are in Adobe Acrobat (PDF) format so you will need a copy of the acrobat reader which is available with all the latest browsers or you can download a copy at: adobe.com

 
On-Line Registration Form

CONTACT INFORMATION

*Required Fields in Bold letters
Course Being Taken:
Student Name: A value is required. 
E-mail Address: A value is required.Invalid format.
Home Phone: A value is required.Invalid format.
Fax Number: Invalid format.
Work Phone: Invalid format.
Address:
Address:
City,State,Zip,Country:
Date of Birth: Sex:
Current Occupation:
   

SAFETY QUESTIONS

 
1. Can you swim?
2. Do you have any learning or physical disability that would prevent you from fully participating in this course? If yes then describe.
3. Who should we contact in an emergency?
 

REASONS FOR TAKING THIS COURSE

1. As a follow-up to having completed other formal training through: (Check all that apply)

Course

Location

Date
2. To gain expertise in powerboat handling skills for personal use.
3. Do you currently own a powerboat?
If so, Manufacturer, Length, Year and how is it powered?
Questions or Comments:

The course candidate assumes full responsibility for any loss or damage, excepting loss or damage covered by insurance, that may come to any person, boat, pier, float, or other property used in conjunction with this course as the result of improper use, negligence, violation of the Navigation rules and racing rules, and other acts of boaters, or other representatives of the host location in connection herewith. The course candidate further agrees to hold the host location, POWERBOAT SAFETY & OPERATING SCHOOL, US POWERBOATING and their representatives harmless for personal injuries and/or property damage.

Return the Medical form, and Skills Self-Assessment form, along with payment to POWERBOAT SAFETY & OPERATING SCHOOL, 105 15th Ave. SE, St. Petersburg, FL 33701.

Signature of Adult or Guardian Printed Name Date

A value is required.Minimum number of characters not met.Exceeded maximum number of characters.
 
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