Note: Fill out this form and then print it
on your printer. Send the form and payment to the certification
agency (Not High Sierra Divers)
YMCA LOST CARD REPLACEMENT FORM
National YMCA Underwater Activities program, Atlanta Office,
Oakbrook Square, 6083-A, Oakbrook Parkway , Norcross. GA 30092
The below named student lost his/her certification
card and would like a replacement.
The student was certified by myself and met the YMCA Scuba Program
requirements at the time of his/her certification.
Enclosed is a CCB card and photograph for this
student with a check in the amount of $ 25 payable to National
Board of YMCA's for this student requesting a replacement card.
