Emergency Contact Information

First and Last Name:

Relationship:

Phone Number:

Military Branch/LEO/EMT/FIRE PRECINT

Rank/Pay Grade

Dates of Service:

Describe Injury/disability sustained while serving please:

If you are a Military Veteran, please provide a copy of your redacted DD-214 to include blocks 23-30. Please black out your SSN when you upload your DD-214. (NOTE: If you are a First Responder with no DD-214 or a member of the military actively serving please upload a picture of your department issued ID card)

DD-214

Upload File

Referral/etc.

The following questions will determine if you you will be selected for the SCUBA scholarship. Please answer the below questions with as much detail as possible. Use of examples are encouraged.

BIO-Minimum of 250 words. (Word counter can be found at www.wordcounter.net) Please tell us about yourself (family, hobbies, interests, etc.), your military, LEO, EMT, and/or firefighting career. We want to know YOU!!! Please use discretion.

Describe how your medical disability has impacted your life and how do you think a SCUBA certification would improve your life?

HSG’s mission is to help Veterans and First responders with their diagnosed PTSD and/or depression. There are other Non-Profits that help this specialized community in other ways, why have you chosen to apply for this lifetime certification? How do you think this will help you? (MIN 250 words) (Word count tool can be found at www.wordcounter.net)

HSG continues to seek engagement with all their Alumni, after receiving this lifetime certification, how would you continue the mission? What are your plans to engage with HSG after certification?

I understand that I will be emailed a link to a medical questionnaire and it is a requirement of Hero Scuba Group the form be completed and signed by a Qualified Medical Professional in order for my application to move forward in the consideration process.

Yes, I understand.

No, I don't want to.

Thank You for submitting! Your application has been discreetly sent to the decision staff.