Bluegrass Dive Club
Lexington, Kentucky

Membership Application Form

Bluegrass Dive Club
Membership Application/Directory Update

Check One: New Member           Directory Update
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
Occupation:  
Company:  
Business Phone:        Extension:
Business Address:  
City:        State:     Zip:
Business E-Mail Add:  
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 for Family memberships only - please list additional family members

NAME

Diver?

Email Address**

DOB* Include in
Directory

1st additional family member

Yes
No
Yes
No
2nd additional family member
Yes
No
Yes
No

3rd additional family member

Yes
No
Yes
No

4th additional family member

Yes
No
Yes
No

* To determine  voting eligibility
** Leave blank if family member does not wish to receive newsletter or announcements

    

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

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