Diving Emergency Specialist

Diving Emergency Specialist

PROVIDER APPLICATION

A RECOGNITION PROGRAM FROM DAN

Sign up for the DES QUEST! Qualify June 1 - Dec. 31 • See www.DiversAlertNetwork.org
DAN believes safe divers are those who continue to seek out training and improve their skills. By continuing to learn about dive safety and the care of injured divers, you have obtained a truly unique status.

To receive your Diving Emergency Specialist recognition from DAN, please submit to DAN Training a completed copy of this application, along with photocopies of current certifications for the following:

(check off)
� ❏ Oxygen First Aid for Scuba Diving Injuries (or equivalent)
� ❏ Current CPR and First Aid ratings
� ❏ Rescue Diver certification
� ❏ Application fee of $20

and Three of the following
� ❏ Advanced Oxygen First Aid for Scuba Diving Injuries (or equivalent)
� ❏ First Aid for Hazardous Marine Life Injuries (or equivalent)
� ❏ Automated External Defibrillators (AEDs) for Scuba Diving (or equivalent)
� ❏ On-Site Neurological Assessment for Divers (or equivalent)
� ❏ DAN REMO2 TM
� ❏ OR a current DAN Diving Emergency Management Provider certification, which includes Advanced Oxygen

PERSONAL INFORMATION

Name _________________________________________________
DAN Member #__________________
Address__________________________________________ City_______________________________
State/Province _________________ Zip/Postal Code______________ Country_______________
Contact Phone ______________________________ Email __________________________________
Shirt Size: ❏ M ❏ L ❏ XL ❏ 2XL

PAYMENT INFORMATION

❏ Check — Payable to DAN in U.S. dollars and drawn on a U.S. Bank
❏ MasterCard ❏ VISA ❏ American Express ❏ Discover
Card Number (13-16 numbers) ______________________________ Exp. Date_________________
Cardholder Name _____________________________________________________________________
Signature ___________________________________________________________________________

TRAINER INFORMATION

DAN Instructor _________________
Dive center affiliation (if any)___________ Instructor Name _________________________
Name to be entered in drawing (individual instructor or dive center) ____________________
* For pro drawing only; individual divers are automatically entered.

Mail the completed form to: DAN Training, 6 West Colony Place, Durham, NC 27705
or fax it to: +1-919-490-6630 or email: oxygen@DiversAlertNetwork.org