About Boating Safely (Abs) Student Registration Form

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TERRA ENVIRONMENTAL RESEARCH INSTITUTE’S
PARENT TEACHER STUDENT ASSOCIATION &
UNITED STATES COAST GUARD AUXILIARY
DISTRICT 7 ▪ DIVISION 6 ▪ FLOTILLA 61
ABOUT BOATING SAFELY (ABS)
SINGLE-SESSION INSTRUCTIONAL PROGRAM
OCTOBER 24, 2015 ▪ 8:00AM – 5:00PM
STUDENT REGISTRATION FORM
(PLEASE PRINT)
LAST NAME
FIRST NAME
MIDDLE INITIAL
HOME ADDRESS
CITY
STATE
ZIP CODE
(
)
(
)
HOME PHONE
MOBILE PHONE
E-MAIL ADDRESS
BIRTH DATE (MMDDYY)
GENDER
IF YOU ARE A BOAT OWNER, PLEASE TELL US:
MAKE: ________________________ MODEL: _______________ LENGTH: _______ □ POWER □ SAIL
HOW DID YOU FIND OUT ABOUT THIS PROGRAM? (Please select one)
□
□
□
□
U.S. Coast Guard
Web Site
_________________
E-Mail
Newspaper Ad
(Please specify)
□
□
□
□
Family Member
Friend
Another Boater
Other Source
_______________
(Please specify)
INSTRUCTIONAL MATERIALS:
You may want to purchase a copy of the About Boating Safely text book to keep as a review tool and for future
reference. You are not obligated to buy this text book to take this program.
ABOUT BOATING SAFELY TEXT BOOK: $20
Payment can be made by cash or check. Checks should be made payable to: PTSA
□
□
Instructional Material Paid By:
Cash
Check (No. _________)
Date: _____________ Initial: ________

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