Booking Form. All participants of Dart Marine Academy courses are required to provide next of kin contact details and a medical declaration, prior to starting their course. Booking Form Course Details.Course Title(Required) Start Date(Required) MM slash DD slash YYYY Finish Date(Required) MM slash DD slash YYYY Participant Details.Title(Required)MrMrsMissMsSirDrFirst Name(s)(Required) Last Name(Required) Email(Required) Phone(Required)Gender(Required)MaleFemaleDate of birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City Post Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Next Of Kin Details.Next of kin(Required) Relationship to participant(Required) Emergency contact telephone(Required)Medical Details.Please answer the following questions but be assured that answering "Yes" will not necessarily prevent you from taking a full part in your chosen course.Do you suffer from any of the following conditions?(Required) Epilepsy, Giddy spells, Asthma, Diabetes, Angina, or other heart conditions? Back or neck problems? Do you have any current medical condition not shown above? Are you currently taking any medication? Do you have any disability/ concerns relating to your health during this course? Can you swim more than 50m unaided? Medical Declaration(Required) I declare that the responses I have provided above are correct to the best of my knowledge and I know no reason related to my health and well-being that will prevent me from undertaking this course. I will inform the instructor immediately should I have any difficulties during the course.Privacy Policy, Terms & Conditions(Required) I consent to the above details being used to contact me. I have read and agree to the Dart Marine Academy Terms & Conditions.Photography(Required) I consent to photos and videos being taken of me during the course for Dart Marine Academy marketing purposes.Signed(Required) Date(Required) MM slash DD slash YYYY Signed by parent / guardian if participant under the age of 18 Consent I agree to the privacy policy.Consent(Required) I agree to the privacy policy.
