Membership Application Form, DEV Bluegrass Dive Club

Name:

Nickname:

Phone:

Address:

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code

Email:

Include in Directory?

Yes

No

Information will be available to other Members only.

Diving Certification Level:

Certifying Agency:

How did you find us?

Specialties: Remarks / Comments: or Address if non-US:

CPR Certified?

Yes

No

CPR Expiration Date:

Membership Type:

Please click HERE for explanation of membership types.

* Date of birth is used to determine voting eligibility for Club elections.

** Leave Email blank if family member does not wish to receive Club newsletter or announcements.

Name (1):

Date of Birth (1):

day

/

month

/

year

Diver (1)?

Yes

No

Email (1):

Include in Directory (1)?

Yes

No

Name (2):

Date of Birth (2):

day

/

month

/

year

Diver (2)?

Yes

No

Email (2):

Include in Directory (2)?

Yes

No

Name (3):

Date of Birth (3):

day

/

month

/

year

Diver (3)?

Yes

No

Email (3):

Include in Directory (3)?

Yes

No

Name (4):

Date of Birth (4):

day

/

month

/

year

Diver (4)?

Yes

No

Email (4):

Include in Directory (4)?

Yes

No

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