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Student information

Ready to get started? Just complete this form. It will provide us with all the information we need for your student record. It also asks several important medical history questions.

If you can answer No to all of the medical questions, you will not have to get a doctor’s approval to take the course. And if you must answer Yes to one or more questions, we can make the process of getting that approval easier.

Each person taking the course must fill out this form separately. Be aware that your enrollment will not be considered confirmed until we receive payment and you get confirmation concerning dates.

Basic Information

First Name

Middle Initial

Last Name

Parent/Guardian Name if under 18

Street or Mailing Address

City

State

Zip Code

Phone (mobile is best)

Date of Birth

Gender

Male Female

Current certification level (if any)

Which course are you interested in?

Desired starting date

Emergency contact name

Mobile phone

Relationship

Medical History

I have had problems with my lungs/breathing, heart or blood.

Yes No

I am over 45 and currently smoke or inhale nicotine by other means.

Yes No

I am over 45 and have a high cholesterol level.

Yes No

I am over 45 and have high blood pressure.

Yes No

I am over 45 and have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).

Yes No

I struggle to perform moderate exercise (for example, walk 1.6 kilometer/one mile in 14 minutes or swim 200 meters/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.

Yes No

I have had problems with my eyes, ears, or nasal passages/sinuses.

Yes No

I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.

Yes No

I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.

Yes No

I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability.

Yes No

I have had back problems, hernia, ulcers, or diabetes.

Yes No

I have had stomach or intestine problems, including recent diarrhea.

Yes No

I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine/Lariam).

Yes No

Additional Info

How did you hear about us? (Check all that apply)

Google or othter Word of mouth Facebook Instagram Twitter Other social media Yelp

Any questions?

Important: If, after clicking the Send button, you do not see a message indicating that the form was successfully sent, it most likely means you did not fill out a required field. Please supply the missing information and try again.

3852 NE 172 Ct
Williston, FL 32696
(352) 528-5770

Open daily 8-5
Closed Thanksgiving, Christmas Eve, Chrismas Day and Easter

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