Bluegrass Dive Club
Lexington, Kentucky

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Membership Application Form

Name:  
Nickname:        Birth date:
Home Phone:  
Home Address:  
City:         State:     Zip:
Home E-Mail Add:  
Include in Directory? YES      NO   Information will be available to other members only
Certification Level:            Agency:
How did you find us:   (Hold Ctrl for multiple selections)
Specialties:
Remarks/Comments:
or Address if Non-US:
 
CPR Certified?:   Yes           No          Expiration Date:
Membership Type:  
  Click HERE for explanation of Membership Types

Following is for Family memberships only - please list additional family members:
Please note: To qualify as an additional family member they must live at your address full time with the exception of a student living away temporarily for school.

* Date of birth is user to determine  voting eligibility in Club elections
** Leave Email blank if family member does not wish to receive newsletter or announcements

1st additional family member

Name:  
*Date of Birth:
Diver?: Yes  No
**Email Address:  
Include in Directory?: Yes  No

2nd additional family member

Name:  
*Date of Birth:
Diver?: Yes  No
**Email Address:  
Include in Directory?: Yes  No
3rd additional family member
Name:  
*Date of Birth:
Diver?: Yes  No
**Email Address:  
Include in Directory?: Yes  No
4th additional family member
Name:  
*Date of Birth:
Diver?: Yes  No
**Email Address:  
Include in Directory?: Yes  No
    

For a Microsoft® Word printable version of this form - Click Here
For a PDF printable version of this form - Click Here

Home ] Up ] News ] What's New ] Update E-mail ] Guest Book ] DiveAssure ] Officers ] Meetings ] Local Diving ] Newsletter ] Upcoming Events ] Diving Documents ] Trip Reviews ] Weather ] BY-LAWS ] Links ] Site Map ] Search ] 2D Codes ] Copyright ] Acknowledgments ]

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Copyright © 1999 Bluegrass Dive Club
This Page was last modified 08/18/16