Class Registration Form

Please fill out this form for each member attending the school. Spots in classes are given on a first come first serve basis. Reservations are not final until payment is received and confirmation is given. Submitting this form will time stamp your request and ensure your request is received before it would if you mailed it.

IRRS does accept mailed in forms, with payment. You can print this page after you filled it out, make sure your payment is enclosed with the form. Please contact the school administrator if you have any questions:

IRRS Administration Office, Phone (574) 235-9255 Email admin@indianariverrescue.com

Student Information:

First Name:*
Last Name:*
Address:*
Address 2:
City:*
State:*
Zip Code:*
Country:*
Phone Number:*
Email Address:

Department Information:

Department Name:
Contact:
Title:
Address:
Address 2:
Department City:
Department State:
Department Zip:
Department Phone:
Fax Number:

Operations/Technician Level Classes (cost $500.00):

Please choose a First, Second and Third choice for your class dates. All efforts will be made to accommodate you first choice

Technician Level Choice #1 September 13-17, 2010

Technician Level Choice #3 September 13-17, 2010

Technician Level Choice #2 September 13-17, 2010

Experience:

Are you attending with other members of a group? Yes No
Are you currently a member of a Water Rescue Team? Yes No
If yes, how many years experience?
If yes, how many members are on your team?
What other water rescue schools have you attended? Rescue 3 Dive International IRRS Year
Other Classes: Certification:
Other Related Rescue Classes: