Difr Enrollment

Enrollment Application: Difr Dive, Difr Dive +, Difr Teen, & Difr Deep Dive Coaching

In which Difr program are you enrolling?

Full Legal Name (as it appears on your passport or driver's license) *

First

Middle

Last

Nickname/Preferred First Name

if different than legal name

Date of Birth *

Preferred Gender *

How did you hear about our program? *

Permanent Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Alternate Phone

Primary Email Address *

Alternate Email Address

Citizenship *

Citizenship 2

only if dual citizen

Highest Level of Education Completed *

Current Workplace, Organization, or School *

If applicable. If not, enter N/A.

Current Position or Role *

If applicable. If not, enter N/A.

Are you hoping to complete your Difr program with a friend or partner (and each receive $100 off)? *

When are you hoping to begin your Difr program? *

If necessary, please provide any additional information regarding when you hope to begin your Difr program.

What most interests you about Difr? *

Is there anything else you would like us to know? *

Phone

69569