Membership Application Form Membership Information Name: Nickname: Phone: Address: Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Email: Include in Directory?YesNoInformation will be available to other Members only. Diving Certification Level: Certifying Agency: How did you find us?Please Tell Us How You Found BGDCRecommended by current BGDC MemberRecommended by a non-member diverFound BGDC on the webSuggested by Dive shop (please name in comments)Saw our Logo somewhereOther - Please explain in "comments" Specialties: Remarks / Comments: or Address if non-US: CPR Certified?YesNo CPR Expiration Date: Membership Type:Please Select Membership TypeNon-Diving Family ($30.00)Single or Family w/ 1-diver ($30.00)Family with 2 or more divers ($40.00)New Diver - 1st year ($10.00)Student membership with student ID ($10.00)Please 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 used to determine voting eligibility for Club elections.** Leave Email blank if family member does not wish to receive Club newsletter or announcements.1st Additional family member Name (1): Date of Birth (1):01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Diver (1)?YesNo Email (1): Include in Directory (1)?YesNo2nd Additional family member Name (2): Date of Birth (2):01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Diver (2)?YesNo Email (2): Include in Directory (2)?YesNo3rd Additional family member Name (3): Date of Birth (3):01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Diver (3)?YesNo Email (3): Include in Directory (3)?YesNo4th Additional family member Name (4): Date of Birth (4):01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Diver (4)?YesNo Email (4): Include in Directory (4)?YesNoSubmit ApplicationReset Form reCAPTCHAFor a Microsoft Word printable version of this form - Click HereFor a PDF printable version of this form - Click Here
